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Ulcerations&#44; bleeding and obstruction of vital structures can also occur during this phase&#44; especially in preterm infants&#46; Second&#44; the spontaneous regression phase &#8211; complete or partial &#8211; involves a higher risk of deformities and ulceration&#46; Finally&#44; the plateau phase &#40;in which there is no regression or evolution&#41; arises in approximately 10&#37; of cases&#44; requiring therapeutic intervention&#44; as there is a risk of permanent deformation&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This report describes two cases of nasal tip IH treated with oral propranolol&#46; Both showed excellent therapeutic responses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">Six-month-old infant&#44; female&#44; presented an erythematous violaceous vascular lesion with increased local volume at the nose tip&#44; compatible with IH &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The lesion appeared in the first days of life as a slightly erythematous macule and manifested progressive enlargement&#46; Born Appropriate for Gestational Age &#40;AGA&#41;&#44; full-term infant&#44; multiparous mother&#44; without complications during pregnancy or impairments to psychomotor development&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Two-month-old infant&#44; female&#44; presented a violaceous vascular lesion at the nasal tip&#44; surpassing the anatomical limits&#44; compatible with IH &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The lesion appeared in the first days of life as a slightly erythematous and violaceous macule and manifested progressive enlargement&#46; AGA&#44; preterm birth &#40;36 weeks&#41;&#44; primiparous mother&#44; in vitro fertilization&#44; with threat of placental abruption and interruption due to oligodramnium&#44; without changes in neuropsychomotor development&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In both cases&#44; patients underwent cardiologic&#44; pulmonary and laboratorial tests&#44; which did not reveal any alterations&#46; In relation to the therapy&#44; the target dose of propranolol was 2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; bid during meals &#40;first 2 weeks with 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day and a fortnightly progressive increase&#41; over 12 months&#46; The patients were carefully monitored before treatment and when the drug dose was increased&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The infants developed none of the reported side effects &#8211; sleep disturbances&#44; hypoglycemia or hypotension &#8211; and achieved total involution without deformities or residuals scars&#44; demonstrating the efficacy of oral propranolol and its advantages in relation to corticosteroids&#46; The patients did not present recurrence in the 3 months that followed &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">In view of possible complications&#44; effective treatment without side effects is necessary&#46; Formerly&#44; for IH located in the nasal tip&#44; systemic corticosteroids&#44; laser therapy and surgical excision were the most common therapeutic options to delay or interrupt the growth of the vascular tumor and enable its removal&#46; High doses of corticosteroids during prolonged periods are frequently accompanied by several side effects&#44; particularly in children&#44; such as decreases in bone formation and increases in its absorption&#44; proximal weakness and reduction of bactericidal activity&#44; facilitating infections&#46; In addition&#44; consequences can include increased hepatic gluconeogenesis&#44; increased insulin resistance&#44; psychosis and mood changes&#46; Equally&#44; laser therapy and surgical removal can lead to unesthetic scars&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Hence&#44; the use of effective drugs with fewer side effects is paramount&#46; Beta-blockers&#44; specifically propranolol&#44; therefore became the first line of therapy and were approved by the Food and Drug Administration in March 2014&#46; However the use in Brazil is not yet widespread&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Beta-Blockers &#40;BB&#41; are beta-adrenergic antagonists that generate systemic actions&#44; including reduction of cardiac output through a decrease in sinoatrial node activity&#46; This provokes hypotension&#44; causing reflex peripheral vasoconstriction&#44; which is believed to be responsible for involution of the hemangioma&#46; Furthermore&#44; BBs can generate bronchoconstriction&#44; increases in sodium retention and plasma volume secondary to the reduction in renal perfusion&#44; as well as decreased glycogenolysis and glucagon secretion&#44; predisposing to hypoglycemia&#46; Specifically concerning the treatment of IH&#44; BBs have been linked to hypoglycemia&#44; nightmares and hypotension&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;6&#44;8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding the risks involved&#44; it is necessary to perform cardiologic and pulmonary evaluation before treatment&#46; Initially&#44; an Electrocardiogram &#40;ECG&#41; must be requested and Blood Pressure &#40;BP&#41;&#44; Cardiac Frequency &#40;CF&#41; must be checked&#44; combined with detailed cardiologic and pulmonary physical examination&#46; At the beginning of treatment &#40;the first dose or upon an increase in the dose&#41; the following should be checked every hour during the 4<span class="elsevierStyleHsp" style=""></span>h period&#58; temperature&#44; CF&#44; respiratory rate and pulmonary auscultation&#46; Many authors recommend that ECG and capillary glycemia must also be performed prior to administration&#44; and 120 and 240 min thereafter&#44; thus avoiding the risk of hypotension&#44; bronchospasm and hypoglycemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;8&#44;9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Compared to corticosteroids&#44; BBs induce a faster response&#44; with a response rate of around 90&#37;&#46; Moreover&#44; there is a lower risk of relapse and a decreased need for surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;8&#44;10</span></a> In our experience&#44; propranolol has resulted in excellent therapeutic response and safety&#44; as exemplified by the two aforementioned cases&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217;s contributions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Mariana Carvalho Costa&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analysis&#44; and interpretation of the data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Odil Garrido Campos de Andrade&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analysis&#44; and interpretation of the data&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Leth&#237;cia de Castro Pereira&#58; Approval of the final version of the manuscript&#59; elaboration and writing of the manuscript&#59; critical review of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Izelda Maria Carvalho Costa&#58; Approval of the final version of the manuscript&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analysis&#44; and interpretation of the data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infantile hemangioma is the most common pediatric vascular tumor&#44; with the following risk factors&#58; low birth weight&#44; prematurity&#44; white skin&#44; female gender&#44; multiparity and advanced maternal age&#46; The use of oral and topical beta-blockers&#44; although recent&#44; has emerged as the first line of treatment&#44; with superior safety and efficacy to previously used therapies&#44; such as corticosteroids and surgeries&#46; This report describes two cases of nasal tip infantile hemangioma&#44; treated with oral propranolol&#46; Both presented excellent therapeutic responses&#46;</p></span>"
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Case Report
Success in the use of oral propranolol in the treatment of infantile hemangioma in nasal tip – Report of two cases
Mariana Carvalho Costaa,b, Odil Garrido Campos de Andradeb,
Autor para correspondência
odilgca@hotmail.com

Corresponding author.
, Lethícia de Castro Pereirab, Izelda Maria Carvalho Costaa
a Service of Dermatology, Hospital Universitário de Brasília, Brasília, DF, Brazil
b Faculdade de Ciências da Saúde e Educação, Centro Universitário de Brasília, Brasília, DF, Brazil
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Ulcerations&#44; bleeding and obstruction of vital structures can also occur during this phase&#44; especially in preterm infants&#46; Second&#44; the spontaneous regression phase &#8211; complete or partial &#8211; involves a higher risk of deformities and ulceration&#46; Finally&#44; the plateau phase &#40;in which there is no regression or evolution&#41; arises in approximately 10&#37; of cases&#44; requiring therapeutic intervention&#44; as there is a risk of permanent deformation&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This report describes two cases of nasal tip IH treated with oral propranolol&#46; Both showed excellent therapeutic responses&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">Six-month-old infant&#44; female&#44; presented an erythematous violaceous vascular lesion with increased local volume at the nose tip&#44; compatible with IH &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The lesion appeared in the first days of life as a slightly erythematous macule and manifested progressive enlargement&#46; Born Appropriate for Gestational Age &#40;AGA&#41;&#44; full-term infant&#44; multiparous mother&#44; without complications during pregnancy or impairments to psychomotor development&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Two-month-old infant&#44; female&#44; presented a violaceous vascular lesion at the nasal tip&#44; surpassing the anatomical limits&#44; compatible with IH &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The lesion appeared in the first days of life as a slightly erythematous and violaceous macule and manifested progressive enlargement&#46; AGA&#44; preterm birth &#40;36 weeks&#41;&#44; primiparous mother&#44; in vitro fertilization&#44; with threat of placental abruption and interruption due to oligodramnium&#44; without changes in neuropsychomotor development&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">In both cases&#44; patients underwent cardiologic&#44; pulmonary and laboratorial tests&#44; which did not reveal any alterations&#46; In relation to the therapy&#44; the target dose of propranolol was 2<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#44; bid during meals &#40;first 2 weeks with 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day and a fortnightly progressive increase&#41; over 12 months&#46; The patients were carefully monitored before treatment and when the drug dose was increased&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The infants developed none of the reported side effects &#8211; sleep disturbances&#44; hypoglycemia or hypotension &#8211; and achieved total involution without deformities or residuals scars&#44; demonstrating the efficacy of oral propranolol and its advantages in relation to corticosteroids&#46; The patients did not present recurrence in the 3 months that followed &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">In view of possible complications&#44; effective treatment without side effects is necessary&#46; Formerly&#44; for IH located in the nasal tip&#44; systemic corticosteroids&#44; laser therapy and surgical excision were the most common therapeutic options to delay or interrupt the growth of the vascular tumor and enable its removal&#46; High doses of corticosteroids during prolonged periods are frequently accompanied by several side effects&#44; particularly in children&#44; such as decreases in bone formation and increases in its absorption&#44; proximal weakness and reduction of bactericidal activity&#44; facilitating infections&#46; In addition&#44; consequences can include increased hepatic gluconeogenesis&#44; increased insulin resistance&#44; psychosis and mood changes&#46; Equally&#44; laser therapy and surgical removal can lead to unesthetic scars&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4&#8211;6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Hence&#44; the use of effective drugs with fewer side effects is paramount&#46; Beta-blockers&#44; specifically propranolol&#44; therefore became the first line of therapy and were approved by the Food and Drug Administration in March 2014&#46; However the use in Brazil is not yet widespread&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Beta-Blockers &#40;BB&#41; are beta-adrenergic antagonists that generate systemic actions&#44; including reduction of cardiac output through a decrease in sinoatrial node activity&#46; This provokes hypotension&#44; causing reflex peripheral vasoconstriction&#44; which is believed to be responsible for involution of the hemangioma&#46; Furthermore&#44; BBs can generate bronchoconstriction&#44; increases in sodium retention and plasma volume secondary to the reduction in renal perfusion&#44; as well as decreased glycogenolysis and glucagon secretion&#44; predisposing to hypoglycemia&#46; Specifically concerning the treatment of IH&#44; BBs have been linked to hypoglycemia&#44; nightmares and hypotension&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;6&#44;8</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding the risks involved&#44; it is necessary to perform cardiologic and pulmonary evaluation before treatment&#46; Initially&#44; an Electrocardiogram &#40;ECG&#41; must be requested and Blood Pressure &#40;BP&#41;&#44; Cardiac Frequency &#40;CF&#41; must be checked&#44; combined with detailed cardiologic and pulmonary physical examination&#46; At the beginning of treatment &#40;the first dose or upon an increase in the dose&#41; the following should be checked every hour during the 4<span class="elsevierStyleHsp" style=""></span>h period&#58; temperature&#44; CF&#44; respiratory rate and pulmonary auscultation&#46; Many authors recommend that ECG and capillary glycemia must also be performed prior to administration&#44; and 120 and 240 min thereafter&#44; thus avoiding the risk of hypotension&#44; bronchospasm and hypoglycemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;8&#44;9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Compared to corticosteroids&#44; BBs induce a faster response&#44; with a response rate of around 90&#37;&#46; Moreover&#44; there is a lower risk of relapse and a decreased need for surgical intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;8&#44;10</span></a> In our experience&#44; propranolol has resulted in excellent therapeutic response and safety&#44; as exemplified by the two aforementioned cases&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Financial support</span><p id="par0065" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Authors&#8217;s contributions</span><p id="par0070" class="elsevierStylePara elsevierViewall">Mariana Carvalho Costa&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analysis&#44; and interpretation of the data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Odil Garrido Campos de Andrade&#58; Approval of the final version of the manuscript&#59; conception and planning of the study&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analysis&#44; and interpretation of the data&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Leth&#237;cia de Castro Pereira&#58; Approval of the final version of the manuscript&#59; elaboration and writing of the manuscript&#59; critical review of the manuscript&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Izelda Maria Carvalho Costa&#58; Approval of the final version of the manuscript&#59; elaboration and writing of the manuscript&#59; obtaining&#44; analysis&#44; and interpretation of the data&#59; effective participation in research orientation&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Infantile hemangioma is the most common pediatric vascular tumor&#44; with the following risk factors&#58; low birth weight&#44; prematurity&#44; white skin&#44; female gender&#44; multiparity and advanced maternal age&#46; The use of oral and topical beta-blockers&#44; although recent&#44; has emerged as the first line of treatment&#44; with superior safety and efficacy to previously used therapies&#44; such as corticosteroids and surgeries&#46; This report describes two cases of nasal tip infantile hemangioma&#44; treated with oral propranolol&#46; Both presented excellent therapeutic responses&#46;</p></span>"
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                          "autores" => array:6 [
                            0 => "V&#46; Sans"
                            1 => "E&#46;D&#46; de la Roque"
                            2 => "J&#46; Berge"
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                            4 => "F&#46; Boralevi"
                            5 => "J&#46; Mazereeuw-Hautier"
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                        "fecha" => "2009"
                        "volumen" => "124"
                        "paginaInicial" => "e423"
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                        "link" => array:1 [
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19706583"
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Informação do artigo
ISSN: 03650596
Idioma original: Inglês
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