Intralesional steroid in the era of propranolol for infantile hemangioma- Do we need it?

Published:November 23, 2022DOI:



      Despite its effectivity, there are reports of poor response to propranolol in treatment of infantile hemangioma (IH). The literature is limited on the type of IH, which fails to respond to propranolol. This study was conducted to analyze which type of hemangioma respond poorly to propranolol and the effects of intralesional triamcinolone (IL TMC) in them.

      Material and methods

      In this prospective cohort study, IH was classified as superficial, deep, and mixed. The clinical details were recorded. Propranolol was started in the patients at a dose of 1mg/kg/day and increased to 2-3mg/kg/day. The response to the treatment was evaluated as excellent, good, poor, and no response. IL TMC was given in the non-responding group in a dose of 1-2mg/kg at one month interval for a total of six doses after stopping propranolol.


      Ninety six patients (median age 7 months, M:F= 2:1) were treated. Superficial hemangioma was present in 40 (41.7%), deep in 10 (10.4%), and mixed in 46 (47.9%) patients. The response was statistically better if initiated within four months of age. It was not influenced by the sex, number, site, or size. The response was statistically better in superficial hemangioma. IL TMC was administered in the 16 patients. The response was good or excellent in 10 patients.


      Propranolol will be used as a first line of drug for IH. All superficial IH are likely to respond. There will be a possibility of non-responding mixed or deep IH. Use of IL TMC seems reasonable for IH not responding to propranolol.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Léauté-Labrèze C
        • Harper JI
        • Hoeger PH.
        Infantile haemangioma.
        Lancet. 2017; 390: 85-94
        • Léauté-Labrèze C
        • Dumas de la Roque E
        • Hubiche T
        • Boralevi F
        • Thambo JB
        • Taïeb A
        Propranolol for severe hemangiomas of infancy.
        N Engl J Med. 2008; 358: 2649-2651
        • Xu P
        • Yu Q
        • Huang H
        • Zhang W
        • Li W.
        A self-controlled study of intralesional injection of diprospan combined with topical timolol cream for treatment of thick superficial infantile hemangiomas.
        Dermatol Ther. 2018; 31: e12595
        • Dávila-Osorio VL
        • Iznardo H
        • Roé E
        • Puig L
        • Baselga E.
        Propranolol-resistant infantile hemangioma successfully treated with sirolimus.
        Pediatr Dermatol. 2020; 37: 684-686
        • Caussé S
        • Aubert H
        • Saint-Jean M
        • Puzenat E
        • et al.
        Propranolol-resistant infantile haemangiomas.
        Br J Dermatol. 2013; 169: 125-129
        • Pandey A
        • Gangopadhyay AN
        • Gopal SC
        • et al.
        Twenty years' experience of steroids in infantile hemangioma–a developing country's perspective.
        J Pediatr Surg. 2009; 44: 688-694
        • Cordisco MR.
        Hemangiomas: Clinical pictures.
        in: Mattassi R Loose DA Vaghi M Hemangiomas and Vascular Malformations. 2nd Edition. Springer- Verlag, Milano, Italy2015: 67-76
        • Léauté-Labrèze C.
        propranolol and Beta-Blockers in the medical treatment of Infantile Hemangiomas.
        in: Mattassi R Loose DA Vaghi M Hemangiomas and Vascular Malformations. 2nd Edition. Springer- Verlag, Milano, Italy2015: 97-102
        • Tavakoli M
        • Yadegari S
        • Mosallaei M
        • Aletaha M
        • Salour H
        • Lee WW.
        Infantile Periocular Hemangioma.
        J Ophthalmic Vis Res. 2017; 12: 205-211
        • You Y
        • Li Y
        • Xiao Y
        • Zhang J.
        Propranolol vs. steroids in the treatment of infantile hemangiomas: A meta-analysis.
        Mol Clin Oncol. 2021; 15: 156
        • Holmes WJ
        • Mishra A
        • Gorst C
        • Liew SH.
        Propranolol as first-line treatment for rapidly proliferating infantile haemangiomas.
        J Plast Reconstr Aesthet Surg. 2011; 64: 445-451
        • Baselga E
        • Dembowska-Baginska B
        • Przewratil P
        • et al.
        Efficacy of Propranolol Between 6 and 12 Months of Age in High-Risk Infantile Hemangioma.
        Pediatrics. 2018; 142e20173866
        • Kagami S
        • Kaneko M
        • Katori T.
        Thirty-two Japanese cases of infantile hemangiomas treated with oral propranolol.
        J Dermatol. 2018; 45: 719-722
        • Gupta A
        • Verma A
        • Dhua A
        • Bhatnagar V.
        Vascular Anomalies: A Pediatric Surgeon's Perspective.
        Indian J Pediatr. 2017; 84: 612-617
        • Pandey V
        • Tiwari P
        • Sharma SP
        • Kumar R
        • Singh OP.
        Role of intralesional bleomycin and intralesional triamcinolone therapy in residual haemangioma following propranolol.
        Int J Oral Maxillofac Surg. 2018; 47: 908-912
        • Novoa M
        • Baselga E
        • Beltran S
        • Giraldo L
        • Shahbaz A
        • Pardo-Hernandez H
        Arevalo-Rodriguez I. Interventions for infantile haemangiomas of the skin.
        Cochrane Database Syst Rev. 2018; 4CD006545
        • Zhang L
        • Wu HW
        • Yuan W
        • Zheng JW.
        Propranolol therapy for infantile hemangioma: our experience.
        Drug Des Devel Ther. 2017; 11: 1401-1408
        • Wu C
        • Guo L
        • Wang L
        • Li J
        • Wang C
        • Song D.
        Associations between short-term efficacy and clinical characteristics of infantile hemangioma treated by propranolol.
        Medicine (Baltimore). 2019; 98: e14346
        • Wu W
        • Wang H
        • Hao J
        • Gao Z
        • Li F
        • Chen Y
        Therapeutic efficacy of propranolol for infantile hemangiomas.
        Oral Surg Oral Med Oral Pathol Oral Radiol. 2019; 128: 132-138
        • Mannschreck DB
        • Huang AH
        • Lie E
        • Psoter K
        • Puttgen K.
        Topical timolol as adjunct therapy to shorten oral propranolol therapy for infantile hemangiomas.
        Pediatr Dermatol. 2019; 36: 283-289
        • Yildirimcakar D
        • Demirsoy U
        • Azizoglu M
        • Corapcioglu F.
        Evaluation of Clinical Properties and Treatment Responses of Infantile Hemangioma.
        J Drugs Dermatol. 2020; 19: 1156-1165
        • Bagazgoitia L
        • Torrelo A
        • Gutiérrez JC
        • et al.
        Propranolol for infantile hemangiomas.
        Pediatr Dermatol. 2011; 28: 108-114
        • Blatt J
        • Morrell DS
        • Buck S
        • et al.
        β-blockers for infantile hemangiomas: a single-institution experience.
        Clin Pediatr (Phila). 2011; 50: 757-763
        • Talaat AA
        • Elbasiouny MS
        • Elgendy DS
        • Elwakil TF.
        Propranolol treatment of infantile hemangioma: clinical and radiologic evaluations.
        J Pediatr Surg. 2012; 47: 707-714
        • Chang L
        • Chen H
        • Yang X
        • Jin Y
        • Ma G
        • Lin X
        Intralesional Bleomycin Injection for Propranolol-Resistant Hemangiomas.
        J Craniofac Surg. 2018; 29: e128-e130
        • Phillips RJ
        • Lokmic Z
        • Crock CM
        • Penington A.
        Infantile haemangiomas that failed treatment with propranolol: clinical and histopathological features.
        J Paediatr Child Health. 2014; 50: 619-625
        • Y Düzenli Kar
        • Özdemir ZC
        • Acu B
        • Ö Bör
        Infantile hemangioma: Efficacy of low-dose propranolol and of intralesional bleomycin injection for propranolol non-response.
        Pediatr Int. 2019; 61: 459-464
        • Keller RG
        • Stevens S
        • Hochman M.
        Modern Management of Nasal Hemangiomas.
        JAMA Facial Plast Surg. 2017; 19: 327-332
        • Thayal PK
        • Bhandari PS
        • Sarin YK.
        Comparison of efficacy of intralesional bleomycin and oral propanolol in management of hemangiomas.
        Plast Reconstr Surg. 2012; 129: 733e-735e
        • ST Tan
        • Itinteang T
        • Leadbitter P.
        Low-dose propranolol for infantile haemangioma.
        J Plast Reconstr Aesthet Surg. 2011; 64: 292-299
        • Cardis MA
        • DeKlotz CMC.
        Intralesional Deoxycholic Acid Treatment for Fibrofatty Residua of Involuted Infantile Hemangiomas: A Novel Therapeutic Approach.
        JAMA Dermatol. 2018; 154: 735-737
        • Alsmman AH
        • Mounir A.
        Combined oral propranolol with intralesional injection of triamcinolone acetonide in treatment of infantile periocular hemangiomas.
        Clin Ophthalmol. 2017; 11: 2177-2181
        • Wang WY
        • Wang LH
        • Huang G
        • Lin ZY
        • Lin H.
        Intralesional injection of triamcinolone acetonide for cavernous hemangiomas: A case report.
        Medicine (Baltimore). 2019; 98: e16986