Roderic J Phillips

A Randomized, Controlled Trial of Oral Propranolol in Infantile Hemangioma

BACKGROUND Oral propranolol has been used to treat complicated infantile hemangiomas, although data from randomized, controlled trials to inform its use are limited. METHODS We performed a multicenter, randomized, double-blind, adaptive, phase 2-3 trial assessing the efficacy and safety of a pediatric-specific oral propranolol solution in infants 1 to 5 months of age with proliferating infantile hemangioma requiring systemic therapy. Infants were randomly assigned to receive placebo or one of four propranolol regimens (1 or 3 mg of propranolol base per kilogram of body weight per day for 3 or 6 months). A preplanned interim analysis was conducted to identify the regimen to study for the final efficacy analysis. The primary end point was success (complete or nearly complete resolution of the target hemangioma) or failure of trial treatment at week 24, as assessed by independent, centralized, blinded evaluations of standardized photographs. RESULTS Of 460 infants who underwent randomization, 456 received treatment. On the basis of an interim analysis of the first 188 patients who completed 24 weeks of trial treatment, the regimen of 3 mg of propranolol per kilogram per day for 6 months was selected for the final efficacy analysis. The frequency of successful treatment was higher with this regimen than with placebo (60% vs. 4%, P<0.001). A total of 88% of patients who received the selected propranolol regimen showed improvement by week 5, versus 5% of patients who received placebo. A total of 10% of patients in whom treatment with propranolol was successful required systemic retreatment during follow-up. Known adverse events associated with propranolol (hypoglycemia, hypotension, bradycardia, and bronchospasm) occurred infrequently, with no significant difference in frequency between the placebo group and the groups receiving propranolol. CONCLUSIONS This trial showed that propranolol was effective at a dose of 3 mg per kilogram per day for 6 months in the treatment of infantile hemangioma. (Funded by Pierre Fabre Dermatologie; ClinicalTrials.gov number, NCT01056341.).

Use of propranolol for treatment of infantile haemangiomas in an outpatient setting

Introduction:  Propranolol has recently emerged as an effective drug treatment for infantile haemangiomas. The side effect profile of the drug and the safety of administering propranolol in outpatient settings in this age group remain uncertain. We report our experience with 200 infants and children prescribed propranolol to treat infantile haemangiomas, including 37 patients considered to have a poor response to treatment.

Adverse effects of topical corticosteroids in paediatric eczema: Australasian consensus statement

Atopic eczema is a chronic inflammatory disease affecting about 30% of Australian and New Zealand children. Severe eczema costs over AUD 6000/year per child in direct medical, hospital and treatment costs as well as time off work for caregivers and untold distress for the family unit. In addition, it has a negative impact on a childs sleep, education, development and self‐esteem. The treatment of atopic eczema is complex and multifaceted but a core component of therapy is to manage the inflammation with topical corticosteroids (TCS). Despite this, TCS are often underutilised by many parents due to corticosteroid phobia and unfounded concerns about their adverse effects. This has led to extended and unnecessary exacerbations of eczema for children. Contrary to popular perceptions, (TCS) use in paediatric eczema does not cause atrophy, hypopigmentation, hypertrichosis, osteoporosis, purpura or telangiectasia when used appropriately as per guidelines. In rare cases, prolonged and excessive use of potent TCS has contributed to striae, short‐term hypothalamic‐pituitary‐adrenal axis alteration and ophthalmological disease. TCS use can also exacerbate periorificial rosacea. TCS are very effective treatments for eczema. When they are used to treat active eczema and stopped once the active inflammation has resolved, adverse effects are minimal. TCS should be the cornerstone treatment of atopic eczema in children.

Facial infiltrative lipomatosis

BackgroundAlthough there are multiple case reports and small series concerning facial infiltrative lipomatosis, there is no composite radiological description of the condition.ObjectiveRadiological evaluation of facial infiltrative lipomatosis using plain film, sonography, CT and MRI.Materials and methodsWe radiologically evaluated four patients with facial infiltrative lipomatosis. Initial plain radiographs of the face were acquired in all patients. Three children had an initial sonographic examination to evaluate the condition, followed by MRI. One child had a CT and then MRI.ResultsOne child had abnormalities on plain radiographs. Sonographically, the lesions were seen as ill-defined heterogeneously hypoechoic areas with indistinct margins. On CT images, the lesions did not have a homogeneous fat density but showed some relatively more dense areas in deeper parts of the lesions. MRI provided better delineation of the exact extent of the process and characterization of facial infiltrative lipomatosis.ConclusionFacial infiltrative lipomatosis should be considered as a differential diagnosis of vascular or lymphatic malformation when a child presents with unilateral facial swelling. MRI is the most useful single imaging modality to evaluate the condition, as it provides the best delineation of the exact extent of the process.

Infantile haemangiomas that failed treatment with propranolol: Clinical and histopathological features

To describe the clinical and histopathological characteristics of infantile haemangiomas that failed treatment with oral propranolol .

Headache after lumbar puncture: randomised crossover trial of 22-gauge versus 25-gauge needles

Objectives To compare the frequency of headache and the procedure time following lumbar puncture (LP) using a 25-gauge needle compared to a 22-gauge needle. Design 4-period crossover blinded randomised controlled trial. Setting Oncology unit, Royal Childrens Hospital, Melbourne. Patients Children aged 4–15 years at enrolment having LPs as part of their treatment for leukaemia. Interventions Each child was allocated a random sequence of four LPs, two with a 22-gauge and two with a 25-gauge needle. Outcome measures The presence of post-LP headache. Secondary outcomes included the presence of any headache, procedure time and impact of headache on the family. Results Data on 341 procedures in 93 randomised children were analysed. There was little difference in the incidence of post-LP headache between the two needle sizes (22-gauge 7.2%, 95% CI 3.8 to 12.2; 25-gauge 4.6%, 95% CI 2.0 to 8.9, p=0.3) or in the incidence of any headache (22-gauge 18% 95% CI 12.5 to 24.6; 25-gauge 15%, 95% CI 10.0 to 21.1, p=0.4). Use of the 25-gauge needle was associated with longer procedure times. The incidence of post-LP headache showed little evidence of an age effect (OR =1.1, 95% CI 0.98 to 1.3) and was higher in girls than in boys (11% vs 3%, respectively, OR=3.3, 95% CI 1.3 to 8.4, p=0.014). Fifty-five per cent of families with a child with a post-LP headache assessed the overall functional impact as moderate or severe. Conclusions There was little difference in the occurrence of post-LP headache or any headache between procedures carried out using the 22-gauge or 25-gauge needles. Depending on the circumstances of the procedure and the experience of the operator, either gauge may be appropriate for an LP in a child.

Treatment of acne with oral isotretinoin in patients with cystic fibrosis

Background: Theoretical concerns about liver disease and vitamin A deficiency have limited the use of oral isotretinoin for troublesome acne in adolescents with cystic fibrosis. Methods: Oral isotretinoin was administered to nine patients with cystic fibrosis who had troublesome acne unresponsive to antibiotics. All patients were followed for 1–4 years after cessation of treatment. Results: Isotretinoin treatment cleared active acne lesions in all patients. It was well tolerated, and no patient had significant side effects. All nine patients were pleased or delighted with the improvement in their skin. Conclusions: Adolescents with cystic fibrosis and acne can be treated with oral isotretinoin. Oral isotretinoin should be considered for adolescents with cystic fibrosis who have acne associated with scarring, acne not clearing with topical and antibiotic treatment, acne associated with depression or severe cystic acne.

GIVING PROPRANOLOL TABLETS TO INFANTS WITH HEMANGIOMAS – SOLUBILITY IN WATER

I thoroughly enjoyed reading the May issue of the journal – another eclectic collection. I admit I struggled with the article about the student curriculum program from Lester-Smith et al. The program was described as a ‘mini-clinical evaluation exercise style formative assessment component’, and I remain uncertain about what was ‘mini’ and which adjectives in that phrase attach to which nouns, but an interesting read. Then I went to the Image of the Month showing the child with purplish urticarial lesions after antibiotics. Re the diagnosis of ‘purple urticaria’, it is worth noting that the purplish colour is often non-blanching and, therefore, can indeed be considered true purpura. Finally, there is the probably coincidental juxtaposition of two articles by Frank Shann. The first corrects the Journal for inaccuracies in editorial comments about Richard Dawkins, religion and warfare. The second is the challenging article on children and warfare, pointing out that the diversion of resources to warfare affects the health of the world’s children much more than the actual traumas of war do. That is a message that we should all help to spread.

Consensus statement for the treatment of infantile haemangiomas with propranolol

Although most infantile haemangiomas do not require treatment due to a natural history of spontaneous involution, some require early intervention. The Australasian Vascular Anomalies Network and the Australasian Paediatric Dermatology Network have developed a consensus statement for the treatment of infantile haemangiomas with oral propranolol. Infants with haemangiomas that are life threatening, at risk of ulceration, or at risk of causing a significant functional impairment, psychological impact or physical deformity should be treated early with oral propranolol. Oral propranolol is safe and effective and in most healthy infants oral propranolol can be started in an outpatient setting.

Wound management of ulcerated haemangioma of infancy - an audit: Ulcerated infantile haemangioma

Haemangioma of infancy, a benign tumour of blood vessels, is the most common tumour of infancy. Ulceration, the most common complication, presents a unique wound care challenge. A retrospective audit of medical records of children with haemangioma of infancy who presented to the Royal Childrens Hospital, Melbourne, Australia, between January 2000 and December 2014 was undertaken with an aim to examine wound management of ulcerated haemangioma of infancy. In total, 535 hospital medical records were identified as suitable, of which 352 were randomly selected and audited, of which 84 patients had ulcerated haemangioma of infancy, and 62 were subject to wound management. Of these, 35 were successfully managed by wound dressings, 9 were not fully healed at the time of last review, and 18 were referred for surgical excision. Patients attended an average of five outpatient visits, and the average time from presentation to documented healing was 105 days. There were a total of 225 episodes of wound dressing, for which there was a documented follow‐up appointment at which healing could be assessed. Although a wide range of dressings were used, there was no clear pattern of benefit of one dressing over another. Wounds were less likely to be healed after the use of a silver‐impregnated dressing. Pain was poorly documented. Clinical assessment of whether wounds were infected was of no help in planning treatment. There is considerable variability in the management of this difficult wound group, and further prospective studies are required.