Derm Cases · Dermatology / Paediatrics / Vascular tumours
OSCE — infantile haemangioma: natural history, propranolol, and PHACES screening
An 8-minute OSCE station on recognising infantile haemangioma natural history versus congenital haemangioma, high-risk features needing treatment, oral propranolol dosing and safety, topical timolol for small superficial lesions, and PHACES screening for large segmental facial IH.
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Study tools
Target exams
NEET-PGINICETUSMLEPLABMRCP
Prompt
An 8-minute OSCE station on recognising infantile haemangioma natural history versus congenital haemangioma, high-risk features needing treatment, oral propranolol dosing and safety, topical timolol for small superficial lesions, and PHACES screening for large segmental facial IH.
Brief (to candidate)
A 6-week-old has a rapidly enlarging segmental facial haemangioma >5 cm involving the periocular region. Parents were told “it will go away.” You have 8 minutes to explain natural history, start appropriate therapy, screen for PHACES, and safety-monitor beta-blockade.
Candidate instructions
- Distinguish infantile haemangioma (postnatal proliferation, GLUT1+) from congenital haemangioma.
- Identify high-risk features needing treatment (vision, airway, ulceration, segmental face).
- Prescribe oral propranolol with target dose and duration.
- Screen PHACES for large segmental facial IH.
- Counsel hypoglycaemia, bradycardia, bronchospasm risks and feeding rules.
Examiner checklist (mark each domain / 10)
| Domain | Key actions expected |
|---|---|
| Natural history | Absent or precursor at birth → proliferates first months → slow involution over years (~50% by 5, most by 9); most small lesions need active observation only[6][15] |
| High-risk triggers | Periocular (amblyopia), airway/beard distribution (stridor), ulceration, disfigurement, hepatic multifocal with high-output risk, large segmental face → treat, not watch-and-wait alone[15] |
| First-line drug | Oral propranolol target 2–3 mg/kg/day divided (titrate from lower start per AAP-style protocols); typical course ≥6–12 months through proliferation; topical timolol for small superficial only[7][8][15] |
| PHACES | Segmental facial IH >5 cm → screen MRI/MRA brain, echo, ophthalmology (± other PHACES elements)[15] |
| Safety | Watch HR/BP, hypoglycaemia (feed regularly; hold if poor oral intake), bronchospasm/asthma history; slower titration if PHACES/stroke risk; first doses often supervised[7][15] |
| Not Kasabach–Merritt | Kasabach–Merritt is KHE/tufted angioma, not typical IH — do not mismanage as IH coagulopathy |
| Communication | Correct “it always goes away safely” myth for high-risk sites; set follow-up and residual skin change expectations |
Model key actions
- Start propranolol 2–3 mg/kg/day pathway for high-risk periocular/segmental IH.[7][15]
- Arrange PHACES imaging/cardiac/eye work-up for large segmental facial lesion.[15]
- Teach feeding/hypoglycaemia precautions and when to hold the drug.[7]
Common errors
- Pure observation of periocular or airway-risk IH.
- Omitting PHACES screen for large segmental facial IH.
- Wrong dose (adult beta-blocker thinking) or no hypoglycaemia counselling.
- Treating congenital haemangioma as propranolol-responsive IH without distinguishing natural history.
- Attributing Kasabach–Merritt to ordinary IH.
References4ShowHide
- [6]Léauté-Labrèze C, Harper JI, Hoeger PH. Infantile haemangioma. Lancet, 2017.PMID 28089471
- [7]Léauté-Labrèze C, Voisard JJ, Moore N Oral Propranolol for Infantile Hemangioma. New England Journal of Medicine, 2015.PMID 26176392
- [8]Léauté-Labrèze C, Dumas de la Roque E, Hubiche T, et al. Propranolol for severe hemangiomas of infancy. New England Journal of Medicine, 2008.PMID 18550886
- [15]Krowchuk DP, Frieden IJ, Mancini AJ, et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas. Pediatrics, 2019.PMID 30584062