Propranolol for the Treatment of Infantile Hemangiomas: Practices Vary by Country and Clinician

hemangioma on head
hemangioma on head
An international survey of clinicians assesses practices in prescribing oral propranolol for infantile hemangiomas.

Although oral propranolol is broadly used as first-line treatment for proliferative hemangiomas in infants, propranolol dosing, regimen, and modality varies by practitioner and country of origin, finds survey data published in the British Journal of Dermatology

Investigators invited clinicians from around the world to participate in a 17-item questionnaire regarding the treatment of proliferative infantile hemangiomas. Only practitioners with experience treating infantile hemangiomas were solicited. The questionnaire provided 5 clinical vignettes in which infants presented with hemangiomas under various circumstances. Participants were asked to suggest the appropriate propranolol modality, dosage, and duration of use for each vignette. Data were stratified by the human development index of respondents’ countries of residence: very high and high human development (VHHD and HHD, respectively) and medium and low human development (MHD and LHD).

Overall, 249 respondents submitted complete questionnaires: 184 (74.5%) dermatologists, 40 (16.2%) pediatricians, 21 (8.5%) surgeons, and 2 care providers of other specialties. A total of 52 countries were represented: 215 (88.9%) of VHHD/HHD and 27 (11.2%) of MHD/LHD. The most common country of residence was France (n=49; 20.2%). In the case of non-syndromic infantile hemangiomas, the majority of physicians (58.5%) indicated that they hospitalized infants before introducing propranolol, although this was more common in VHHD/HHD countries than in MHD/LHD countries (62.3% vs 30.8%). Just less than half (46.2%) of respondents indicated that they performed electrocardiography to screen for cardiologic contraindications. Oral propranolol was most often introduced progressively (83.7%), with dosage gradually increased during course of treatment. Propranolol was most frequently given twice a day in VHHD/HHD countries (80.2%) and once a day in MHD/LHD countries (42.3%). Withdrawal of propranolol was typically achieved by tapering (81.5%) during 3 months or less (97.5%). The most commonly cited reasons for tapering were to avoid a rebound effect (54.0%); to be able to easily re-initiate treatment (32.5%); and for better tolerance of withdrawal (28.8%). Nearly two-thirds (62.2%) of respondents indicated that they regularly used other beta-blockers, particularly topical timolol (55.7%), for infantile hemangiomas. Approximately equal percentagesof respondents endorsed 2 mg/kg/day propranolol regimens and 3 mg/kg/day regimens. However, respondents from France appeared to favor the 3 mg/kg/day regimen. Respondents from MHD/LHD countries were more likely to answer “no oral propranolol” as a recommendation for each clinical vignette than their counterparts from VHHD/HHD countries. Expected treatment duration was 6 to 9 months for hemangiomas of the body and 9 to 12 months for hemangiomas of the face.

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These data identify trends in infantile hemangioma treatment worldwide, although clinical practice was still highly varied. The majority of practitioners recommended hospitalization during propranolol introduction. A twice-daily dosing schedule was widely endorsed, and tapering was the most common means of withdrawal. Further study is necessary to identify the most optimal means of propranolol delivery. The researchers noted that results also highlight disparities in resource availability in  VHHD/HHD and MHD/LHD countries.

Disclosure: One study author declared affiliations with the pharmaceutical industry.

Please see the original reference for a full list of authors’ disclosures.


Robert J, Tavernier E, Boccara O, Mashiah J, Mazereeuw-Hautier J, Maruani A. Modalities of use of oral propranolol in proliferative infantile hemangiomas: an international survey among practitioners [published online March 27, 2020]. Br J Dermatol. doi: 10.1111/bjd.19047