A Rare Presentation of Infantile Hemangioma with Arrested Growth Treated Successfully with Oral Atenolol

Case History A 2-month-old term female infant presented to our outpatient dermatology clinic with barely raised, asymptomatic erythematous skin lesion over the right cheek for the past 1.5 months. The lesion was first noticed by the mother 20 days after the birth which minimally increased in size to the current size over the last 1.5 months with no history of ulceration or bleeding episode prior to the day of presentation. On examination, a single erythematous nonblanchable barely elevated plaque of size 4 cm × 5 cm with intervening spared areas of normal skin was present over the right cheek which was extending over the right lower eyelid without any visual compromise [Figure 1]. On dermoscopy, a vasoconstricted patch with an associated vasoconstricted halos were seen with multiple telangiectasia in the periphery of the lesion [Figure 2]. We elected to treat the patient with oral atenolol. Cardiac and respiratory examination, blood glucose, blood pressure, and heart rate were normal. We administered an initial dose of atenolol 0.5 mg/kg/day, and 2 h later, blood glucose, blood pressure, and heart rate were checked which were normal, and the treatment was continued for the next 7 days. After 1 week, the atenolol dose was increased to 1 mg/kg/day and continued the same. One month follow-up showed a significant decrease in the size of the lesion as well as erythema [Figure 3].Figure 1: Erythematous nonblanchable barely elevated plaque of size 4 cm × 5 cm over the right cheekFigure 2: Dermoscopy image showing vasoconstricted patch with an associated vasoconstricted halosFigure 3: Follow up image showing significant decrease in the size of the lesion as well as erythemaDiscussion The growth phase of infantile hemangioma is characterized by rapid proliferation from a few days or weeks until several months of age, and 80% of the final size is usually reached at a mean age of 3 months.[1] Up to half of the cases show premonitory marks and are often recognizable as a well-defined patch of pallor on which IH growth occurs, or alternatively as a telangiectatic or bruise-like patch.[2] A minority of IHs show minimal or arrested growth beyond the stage resembling premonitory marks, and therefore, it is often confused with a vascular malformation in the early stage of evolution. Various clinical appearances of infantile haemangioma with arrested or minimal growth have been mentioned in the literature including fine telangiectasias, coarse telangiectasias, bruise-like areas, and vasoconstricted areas.[3] β-blockers like propranolol and atenolol have become the preferred agents for the treatment.[4] Although propranolol has become the first-line medical therapy for most clinicians to treat infantile hemangiomas, many studies have shown equal efficacy and better side effect profile with oral atenolol as it is a selective β-blockers with once-daily administration which in turn reduces the frequency of vital and sugar monitoring. Furthermore, the standard dose of atenolol is more than 20 times less expensive than equivalent propranolol therapy given at standard dosing.[5] We started our patient on oral atenolol at the rate of 0.5mg per kg per day and increased to 1 mg per kg per day after 1 week. Since cases of infantile hemangioma with arrested growth are rarely reported in the literature, we chose to report this uncommon presentation. Declaration of consent The authors certify that they have obtained all appropriate consent forms, duly signed by the parent(s)/guardian(s) of the patient. In the form, the parent(s)/guardian(s) has/have given his/her/their consent for the images and other clinical information of their child to be reported in the journal. The parents understand that the names and initials of their child/children will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.