Although this constitutes off-label use of these medications, recent studies suggest they have good safety and efficacy ratings.
Beta-blockers and immune modulators are effective in treating several
forms of periocular lesions, according to a physician at OSN New York 2011.
Non-selective beta-blockers offer an important alternative to the
traditional steroidal and surgical treatment of capillary hemangiomas, Jill
Melicher, MD, said.
The established treatment of capillary hemangiomas involves
steroids as well as surgical incision. Interlesional steroids with a
combination of triamcinolone and betamethasone is a good, useful treatment. Its
most severe side effect, however, is embolization, she said.
Capillary hemangiomas, hamartomas, are the most common benign tumors in
children, she said. Young patients can develop abnormalities to the overlying
skin as the lesions grow, requiring difficult reconstructive procedures down
the road. Oral steroids are a good treatment option but come with a significant
systemic side effect profile, including cushingoid appearance, difficulty
sleeping and steroid dependence, Dr. Melicher said.
The beta-blocker propranolol offers a valid, although off-label,
alternative treatment, Dr. Melicher said. It was discovered to be an effective
treatment for infantile hemangioma when decreased redness and softening of
these lesions were observed in patients being treated with the drug for cardiac
The mechanism of action for non-selective beta-blockers involves
vasoconstriction, decreased expression of VEGF and pro-angiogenic growth
factors, and the triggering of hypoxia-induced apoptosis of capillary
endothelial cells. Systemic side effects include bronchospasm, heart block,
hypotension, bradycardia and hypoglycemia, according to Dr. Melicher.
So then it was thought: Well, if we can use systemic
beta-blockers, why cant we use topical beta-blockers to achieve a similar
effect? Dr. Melicher said.
The topical beta-blocker timolol maleate has been an effective treatment
with few drawbacks and no reported systemic side effects, Dr. Melicher said.
The mechanism of action is thought to be similar to that of propranolol, she
In my patients [with] non-amblyogenic capillary hemangioma lesions
on the eyelid, I have tried timolol rubbed into the lesion twice per day with
good effect to promote the involutional phase of the lesion, she said.
Basal cell carcinomas
There are new advancements from the dermatology literature for
nonsurgical treatment of biopsy-proven superficial basal cell and premalignant
actinic keratosis with topical medications. Traditionally these lesions have
been treated with primary excision using frozen section control or Mohs
micrographic surgery, Dr. Melicher said.
Dermatologists have been using topical 5% imiquimod cream to treat
superficial basal cells such as premalignant actinic keratoses, she said. This
medication has been used around the eye for treatment of biopsy-proven
superficial basal cell and actinic keratosis with good effect.
Topical 5% imiquimod is an immune modulator. It induces
pro-inflammatory cytokines followed by cytotoxic T-cell-mediated death,
Dr. Melicher said.
The cream is dosed once daily, 5 days per week for 6 weeks, she
Its [U.S. Food and Drug Administration] approved for use
everywhere but the face, she said, but recent articles have
suggested that it can be useful in facial lesions, as well as periocular
This treatment is indicated only in cases of biopsy-proven lesions, she
When used in the periocular region, side effects such as foreign body
sensation, injection and lid hyperemia have been observed, but the use of
cellulose in the eye largely dissipated these effects, she said.
Topical 5% imiquimod is a useful first-line agent, specifically
for actinic keratoses, but also in patients [with] biopsy-proven superficial
basal cell carcinomas who dont qualify for surgery or [in patients who
have] refused surgical removal, she said. by Daniel R. Morgan
- Bakri SJ, Snyder MR, Reid JM, Pulido JS, Singh RJ. Pharmacokinetics
of intravitreal bevacizumab (Avastin). Ophthalmology.
For more information:
- Jill Melicher, MD, can be reached at Minnesota Eye Consultants, 9801
Dupont Ave. S, Suite 200, Bloomington, MN 55431; 952-888-5800; email:
- Disclosure: Dr. Melicher has no relevant financial disclosures.