Efficacy of Topical Propranolol gel in
Malumani Malan1, Wu Jianbo2 and Song Ji Quan3*
1 Department of Dermatology and Venereology, Zhongnan Hospital of Wuhan University, China
2 Deputy Head of Department of Dermatology and Venereology, Zhongnan Hospital of Wuhan University, China
3Deputy Head of Department of Dermatology and Venereology, Zhongnan Hospital of Wuhan University, China
Submission: October 06, 2018; Published: November 30, 2018
*Corresponding author: Song Ji Quan, Head of Department of Dermatology and Venereology, Zhongnan Hospital of Wuhan University, China.
How to cite this article: Malumani Malan, Wu Jianbo, Song Ji Quan. Efficacy of Topical Propranolol gel in Infantile Hemangioma. Acad J Ped Neonatol.
2018; 7(3): 555769. DOI: 10.19080/AJPN.2018.07.555769
Infantile hemangiomas (IHs) are vascular neoplasms characterized by aberrant proliferation of endothelial cells and abnormal blood vessel
architecture, characterized by an initial phase of rapid proliferation followed by an involutional phase. They are the commonest benign neoplasms
of infancy. We discuss a cases report of a 7-month old male infant who responded well to topical propranolol gel-ointment which offers a nouvelle,
effective and acceptable means of treating Infantile Hemangiomas. Propranolol gel is efficacious in treating IH, with also a low side effects profile
or none at all. This case report offers clinicians a quick review and acceptable alternative approach in management of IH.
Infantile hemangiomas (IHs) are vascular neoplasms characterized
by aberrant proliferation of endothelial cells and abnormal
blood vessel architecture, characterized by an initial phase of rapid
proliferation followed by an involutional phase [1,2]. They are
also referred as infantile capillary hemangiomas,  strawberry
HI usually appears in the initial weeks of life and grows most
rapidly over the first six months. Usually, growth is complete, and
involution has commenced by twelve months . Subhash et al
notes that half of all infantile hemangiomas would have completed
involution by age five years, 70% by age seven, and most of the
remainder by age twelve years.
They are the commonest benign neoplasms of infancy. According
to Darrow et al., the incidence of IH is estimated at approximately
5% of infants and has a female to male predominance ratio
ranges from 1.4:1 to 3:1 . Some attributable risk factors for IH
include the following but not limited to white race, prematurity,
low birth weight, multiple gestation pregnancy, placenta previa,
advanced maternal age, and preeclampsia. Other risk factors may
include in utero diagnostic procedures like chorionic villus sampling
and amniocentesis, use of fertility drugs or erythropoietin,
breech presentation, and being first born . Although most of these neoplasms are small and harmless, 
some may be life- or function-threatening or have associated
structural congenital anomalies . Early lesions may resemble
a red scratch or patch, a white patch, or a bruise. Clinically, the
majority of hemangiomas occur on the head and neck, but they
can occur almost anywhere . The appearance and color of the
hemangioma depends on its location and depth within the level
of the skin, thus categorized as either superficial or deep infantile
Although the pathogenesis of hemangiomas is not well
understood, epidemiological findings and advances in the
knowledge of angiogenesis have provided some clues, such as the
theory of placental origin, the specific marker glucose transporter
1 and the activation of angiogenesis factor angiopoietin-2. This
has become an acceptable unifying theory.
Histological presentation collarets to the clinical phases;
proliferative IHs reveal well-defined masses of capillaries lined
by plump endothelial cells, arranged in lobules, they are often
described as having enlarged draining veins. Involuting phase of
IHs reveals, fibrofatty stroma, residual “ghost” vessels, mast cells,
and apoptotic bodies .
Immunohistochemical staining of IH is positive for glucose
transporter 1 (GLUT1), CD34, CD31, factor VIII–related antigen, and others. Huang et al notes that GLUT1 is the most useful and
widely used marker for the diagnosis of hemangiomas [1,10].
In this case report, we discuss the role of topical propranolol
in the treatment of an innocuous infantile hemangioma.
A healthy looking 7-months old male infant presents to the
Dermatology outpatient of Zhongnan Hospital of Wuhan University
with an history of an increasing skin lesion on the back since birth,
with gradual increase in size. He had no any other complaints.
His Birth and developmental history were unremarkable and
had no significant past medical nor family history. The physical
examination revealed strawberry like lesions on the left lateralposterior
aspect of body about less than 1% of body surface area
and appeared purplish-red lobulated like macules which were
spongy in consistency and non-tender as shown on Figure 1. No
any other investigation was done.
A clinical diagnosis of infantile Hemangioma was made, and
patient was started on a cocktail of Propranolol 150mg in 14g
mucopolysaccharide polysulfide cream, daily application nocte.
It showed significant resolution after one month of application
Figure 2. There was complete resolution at 3-months as seen in
There were no local or systemic side effects observed with the
use of topical propranolol gel -ointment.
The infant was started on a cocktail ointment gel of
Propranolol 150mg in 14g mucopolysaccharide polysulfide cream,
daily application nocte. This application of topical propranolol
was administered by the guardians as an out-patient bases.
This formulation showed significant response and without any
noticeable local or systemic side effects in one month of starting
treatment and complete resolution of the lesion in three months
as shown in Figures 2 & 3 respectively.
The role of systemic use of propranolol is now being advocated
by many physicians in the management of IH [11,12]. Propranolol
has been associated with less severe side effects  in comparison
to systemic corticosteroids. However, topical propranolol may
become a better option for treatment of uncomplicated IH which
require ‘active non-intervention’, a term that is slowly replacing
the term benign neglect. The use of topical propranolol is gaining
ground due to its favorable pharmacokinetics and dynamics .
Despite the knowledge that there is gradual involution of IH
over the next 5–7 years. Fading of lesion usually heralds regression
of the hemangioma, but involution remains unpredictable, 
thus the need for active intervention is advised.
By recognizing that not all hemangiomas are the same,
physicians and parents can make informed choices regarding the
The major goals of management include:
1) Preventing or reversing life- or function-threatening
2) Preventing permanent disfigurement
3) Treating ulcerations
4) Minimizing psychosocial distress to the patients and
their families and
5) Avoiding overly aggressive, potentially scarring
procedures for lesions that have a strong probability of
involuting without significant residua.
For our patient the main reason for treatment was minimizing
psychosocial distress to the guardians, possible complications like
ulcerations which is associated with IH and avoiding potentially
scaring procedures like laser therapy. Thus, one other advantage
of topical propranolol over surgical methods is having less
In addition, the use of topical propranolol offers clinicians an
effective, alternative and acceptable route of management of IH. It
can be used as an adjuvant therapy in selected cases as deemed fit
by clinician. Bota et al. notes that if a clinician does not observe any
appreciate response with four weeks on topical propranolol(betablocker),
then it is a case of non-response to propranolol .
Topical propranolol gel-ointment offers (topical beta blockers)
 a nouvelle, effective and acceptable means of treating Infantile
Hemangiomas. It has shown that it is efficacious with also mild
side effects or none at all [16,17]. It is affordable, safer and can
be used as an out-patient basis with fairly well spaced review