Infantile Haemangioma — SCE Dermatology MCQ

Correct answer: B — Propranolol

The correct answer is B, propranolol. This infant has a classic infantile haemangioma: appeared at 3 weeks of age, bright red, compressible, and rapidly enlarging on the forehead, a high risk site for disfigurement given its size and location. Oral propranolol is the established first-line systemic treatment when intervention is indicated (functional risk, ulceration, or risk of permanent cosmetic disfigurement), working via vasoconstriction, reduced angiogenic signalling and induction of apoptosis in proliferating endothelial cells. UK consensus guidance from the British Society for Paediatric Dermatology and British Association of Dermatologists recommends propranolol as the treatment of choice once a decision to treat has been made, started during the proliferative phase for maximal effect. Treatment is typically titrated to a target of 1 to 3 mg/kg/day in divided doses with cardiovascular and glucose monitoring at initiation. Why the other options are wrong: C. Observation only: appropriate for small, uncomplicated haemangiomas that are not growing rapidly or threatening disfigurement, but this lesion is enlarging and large enough at a cosmetically sensitive site to warrant active treatment once intervention is deemed necessary. A. Intralesional corticosteroid injection: largely superseded by propranolol, carries risks of local tissue atrophy, depigmentation and, for periocular lesions, adrenal suppression, and lacks the systemic efficacy and evidence base propranolol now has. D. Surgical excision: reserved for residual fibrofatty tissue after involution or for pedunculated lesions unresponsive to medical therapy; excising a rapidly proliferating vascular lesion in infancy carries unnecessary bleeding and scarring risk. E. Pulsed dye laser: useful for superficial residual telangiectasia or ulcerated haemangiomas, but has poor penetration for bulky, rapidly proliferating lesions and is not first-line for a growing 3 cm mass. Key point: propranolol is first-line pharmacological therapy for problematic proliferating infantile haemangiomas once treatment is indicated, superseding corticosteroids, surgery and laser in most cases.

Reference: British Society for Paediatric Dermatology and British Association of Dermatologists, Oral propranolol in the treatment of proliferating infantile haemangiomas: consensus guidelines, British Journal of Dermatology 2018;179(3):582-589 (https://doi.org/10.1111/bjd.16779)