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Haemangiomas (he-man-gee-omas) are a common type of birthmark that are sometimes called a strawberry mark because of their bright, red strawberry colour. They often develop shortly after birth and grow fast in the first few months of life. They then stop growing and very slowly shrink and fade away over several years, even without treatment. One in 15 babies will develop a haemangioma.
Haemangiomas usually don’t cause any problems, with most disappearing completely on their own.
As many haemangiomas typically tend to resolve by themselves, most do not need any treatment. However, a haemangioma will need urgent treatment if:
Treatment should be given when the benefits of treatment outweigh the risks involved. All treatments have side effects that your doctor and nurse practitioner will discuss these with you.
Beta blockers are the first line of treatment for haemangiomas. They may be in the form of either gel drops (timolol) applied to the skin or as tablets or a liquid (propranolol or atenolol) taken by mouth. It is not understood how beta blockers work in haemangiomas but in most children, beta blockers will stop further growth of the haemangioma and reduce the size and redness.
Beta blockers are commonly used in children to treat other problems including migraine, glaucoma, high blood pressure and some heart problems. Beta blockers have been used in paediatric health for more than fifty years and have an excellent safety record in young children.
Timolol XE 0.5 per cent gel-forming drops may be used on flat or small haemangiomas. A prescription is required for this medication. Follow the prescribed dose (usually one drop applied morning and evening) – your doctor or nurse practitioner will confirm this with you. Use a clean finger to spread the timolol over the surface of the haemangioma. There is no need to cover the haemangioma with anything afterwards. If the haemangioma develops into an open wound, stop the timolol and contact your doctor or nurse practitioner.
Oral beta blockers can be used to treat larger haemangiomas. The dose is calculated according to your child’s weight. Usually treatment will start on a lower dose and will be increased to the full dose after a few days. The medicine is usually given twice a day with feeds. As your baby grows, the doctor or nurse practitioner may choose to adjust the dose.
Propranolol is available with a prescription as 10mg tablets (many children can take these crushed in a little water or milk, or taken in food for older children), or as a syrup made up by the pharmacist.
The strength is often 5 mg/ml but your doctor may use a different strength, so always follow their instructions.
Atenolol is available with a prescription as a syrup strength of 5mg/ml.
Many children will have cold hands and feet when taking a beta blocker. This is not a problem.
Occasionally a child may develop sleep disturbance, diarrhoea or vomiting when taking oral beta blockers. If this occurs, stop the medicine and consult your doctor or nurse practitioner.
Serious side effects are very rare and include low blood sugar, lowered heart rate and wheezing or worsening of asthma. If your child is drowsy or lethargic stop, the medicine and attend your local GP or your local Emergency Department.
If your child is not feeding normally, stop giving the medicine and contact your doctor or nurse practitioner.
If the haemangioma is responding well, there may be no need to increase the beta blocker dose as your child’s weight increases. Treatment may continue for up to 24 months but in most cases stops around 12 months of age. Beta blockers can be stopped safely without the need for reducing the dose
Some haemangiomas will grow again after stopping treatment. This is often minimal and temporary. However, in some children, the regrowth can be significant and your specialist may recommend restarting treatment for an additional few months
Laser therapy and surgery are other treatment options if beta blockers are unsuccessful or not appropriate for your child. For more information see the
Haemangiomas of infancy (strawberry naevus) fact sheet.
Should I give the dose of oral beta blockers during or after a feed?
As long as your infant is feeding well, this doesn’t matter. If your infant or child is not feeding normally, stop giving the oral beta blocker (see above).
Developed by The Royal Children's Hospital Dermatology Department, Plastic & Maxillofacial Surgery, and Department of General Medicine. We acknowledge the input of RCH consumers and carers.
Reviewed May 2021
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