Delayed-Onset of Multiple Cutaneous Infantile Hemangiomas Due to Propranolol: A Case Report

Infantile hemangiomas are the most common vascular tumors in childhood. In view of its proven effectiveness in such cases, propranolol is the drug of choice. We present the case of a male infant who started treatment with propranolol shortly after birth due to heart disease. After 7 months, when the patient had suffered various respiratory exacerbations, this treatment was suspended. One week later, multiple skin lesions (ie, multifocal infantile hemangiomas) began to appear, with no extracutaneous involvement. It was decided to resume treatment with propranolol, although at lower doses than before, and the skin lesions improved rapidly, with some disappearing completely. Treatment was definitively withdrawn at age 16 months, with only slight recurrence of the lesions. The case described is of multifocal infantile hemangiomas without extracutaneous involvement appearing beyond the neonatal period after treatment with propranolol beginning in the first days of life. The details of the case support the hypothesis that this drug is not only therapeutic but also plays a prophylactic role against infantile hemangiomas. In turn, this supports the recent proposal that this drug may be useful in preventing the growth and spread of tumors with high angiogenic potential. It is postulated that the inhibition of b-adrenergic receptors is associated with multiple intracellular processes related to the progression and metastasis of different tumors. Infantile hemangiomas are the most common vascular tumors in childhood. They usually appear during the first weeks after birth, grow rapidly in the first months of life and involute (partially or completely) in a few years. Accordingly, in most cases no treatment is attempted, and physicians adopt a wait-and-see approach. However, up to 10% of hemangiomas call for treatment, with potential complications such as ulceration, bleeding, visual alterations, airway blockage, excessive growth, and even death.1–5 The first description of the value of propranolol as a treatment of infantile hemangiomas was in 2008. Since then, given its effectiveness, it has become the treatment of choice for complicated infantile hemangiomas.6 Propranolol is a noncardioselective b-blocking drug. It produces effects on vascular proliferation by inducing the apoptosis of vascular endothelial cells, thus decreasing the intravascular pressure of the lesions (vasoconstriction) and producing an antiangiogenic effect, blocking vascular endothelial growth factors and fibroblast growth factors.3 However, no previous reports have been made of cases showing the prophylactic effect of propranolol against the development of new infantile hemangiomas.