Atenolol for Infantile Hemangioma: A Future First‐Line Therapy?

Since the findings of Léauté-Labrèze et al. [1] in 2008, many studies have shown the efficacy of propranolol in infantile hemangioma (IH). Still, its use is not risk-free and adverse events have been documented [2]. Designated by Lee [3] a ‘game changer’, the article of Ábarzúa-Araya et al. [2] showed that atenolol, a cardioselective β-blocker, may be at least as effective as propranolol for the treatment of IH and that patients with respiratory diseases may be treated with atenolol with the theoretical lower risk of bronchial obstruction and other adverse events. Recently, Fernandez Faith et al. [4] documented a shift in the management of IH. Advances in the knowledge and better treatment options have resulted in a transition from a predominantly noninterventionist approach to a more proactive one to treat and prevent complications. In addition to propranolol (approved by the Food and Drug Administration and European Medicines Agency for IH in 2014), other systemic β-blockers, mainly nadolol and atenolol, are being used for IH and have shown similar efficacy and safety when compared to propranolol. Because side effects of treatment during infancy may become visible later in life, the aim of the study of Hermans et al. [5] to describe the physical health and development of children, aged 6 and older, treated for IH during infancy with either propranolol or atenolol, showed that no differences were found between both β-blocker groups in any of the parent reported health outcomes. No additional health concerns or developmental problems were identified during the systematic clinical examination of the children by the paediatrician. Rebound growth of the IH following discontinuation of propranolol is a known phenomenon, with reported incidence of 6%–25%, with several risk factors being described. Baruch et al. [6] conducted a study demonstrating similar IH rebound growth incidence rates following the discontinuation of two oral β-blockers, supporting the non-inferiority of atenolol. Additionally, patients who were treated with atenolol required shorter treatment durations for rebound growth episodes, compared to patients treated with propranolol. With atenolol emerging as a promising alternative for IH therapy, demonstrating comparable efficacy and potentially greater tolerability than propranolol, the retrospective cohort study at a tertiary dermatology clinic published by Shi et al. [7] in this issue of the JEACP, is the first study to compare the efficacy and safety of atenolol at 1.5 mg/kg/day, with the more common 1 and 2 mg/kg/day dosages. The overall findings demonstrate that atenolol is effective in treating IH, achieving a substantial response in almost 90% of infants, over half of whom responded at 1.5 mg/kg/day or less, with minimal side effects. Complete involution at 1.5 mg/kg/day was achieved in over two-thirds of lesions, demonstrating the efficacy of this intermediary dose. Overall, 49.4% of lesions fully involuted, which was slightly lower than previous trials (53% in Ábarzúa-Araya and colleagues). Adverse effects requiring treatment cessation occurred in 3.6% (n = 3), all being behavioural changes. With a longer half-life, that allows less-frequent daily dosing and better compliance, and as a hydrophilic β-blocker, which does not cross the blood–brain barrier, offering a decreased risk of sleep disturbance and cognitive effects, atenolol appears to offer a comparable or superior efficacy to propranolol with fewer side effects and more-favourable posology [8]. The author received no specific funding for this work. The author declares no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analysed in this study.