propranolol , a lipophilic , nonselective beta - blocker , by causing vasoconstriction , inhibition of angiogenesis and induction of apoptosis induces a sustained response in ih . the drug should be instituted with careful monitoring preferably under supervision of a paediatric cardiologist . the response of ulcerated ih to propranolol is good and promising keeping in mind the potentially harmful side effects such as hypoglycaemia , bronchospasm and hypotension . a 4-month - old female child presented with haemangioma since birth , involving the left lower leg near the ankle , with ulceration for the past 2 months . the infant was admitted . after complete evaluation in conjunction with the cardiologist that involved pretreatment cardiac workup and an in - hospital titration of propranolol , the infant was given oral propranolol following the standard treatment protocol . a course of an oral antibiotic was given for a period of 1 week before starting treatment with propranolol . propranolol was given as an oral liquid ( 1 mg / ml ) , at an initial dose of 1 mg / kg daily divided into three equal doses and increased to 2 mg / kg daily after 1 week . the infant was monitored for a 4-h period in hospital after the first dose and 1 week later when the dose was increased . during the 4-h period , for the first 2 weeks , the heart rate and blood pressure were checked twice weekly and thereafter once weekly on a shared - care basis with the paediatric team . however , during the subsequent visit , there was a significant reduction in the size with a change in the colour and texture of the lesion . the lesion healed with an atrophic scar at the site of ulceration [ figures 13 ] . the child is being followed up and there has been no recurrence in the past 6 months . ih treated with propranolol , pretreatment ih , 2 months after the initiation of treatment ih , 4 months after the initiation of treatment ulcerated haemangiomas are often painful in infants ; they incur risk of local or systemic infection and can lead to permanent , unsightly scars . in a retrospective observational study , of ulcerated ihs treated with propranolol , propranolol is a highly effective and safe new treatment modality for those infants who failed to respond to steroids , and those with complications like ulceration as in our case . infants with diffuse ( miliary ) haemangiomatosis are at risk for high - output cardiac compromise . infants with a renal or hepatic dysfunction , underlying cardiovascular disease , asthma , diabetes or glaucoma are not ideal for propranolol . the potential side effects like bradycardia , hypotension and hypoglycaemia which can lead to long - term neurologic sequelae should be kept in mind . the striking effect of propranolol on growing ih can be attributed to three molecular mechanisms : vasoconstriction , inhibition of angiogenesis ( reduced expression of vascular endothelial growth factor [ vegf ] , basic fibroblast growth factor [ bfgf ] , hypoxia inducible factor-1 alpha [ fhif-1amatrix metalloproteinase [ mmp ] ) and induction of apoptosis . they correspond to early ( brightening of the haemangioma surface ) , intermediate ( growth arrest ; [ figure 2 ] ) and long - term ( regression , [ figure 3 ] ) clinical observations . atenolol is a promising alternative to propranolol for the treatment of haemangiomas as it is less likely to produce pulmonary side effects . propranolol when used with proper pre - assessment and monitoring appears to be a promising drug in the treatment of even ulcerated haemangioma where steroids may delay wound healing . propranolol is a highly effective and safe new treatment modality for ulcerated ihs in infants , as in our case . though ulcerated haemangioma of the leg is rare in infants , this is probably the first report in india where ulcerated ih on the leg was successfully treated with propranolol . we conclude that amongst the armamentarium of available therapeutic options , propranolol when used with proper monitoring appears to be a promising drug in the treatment of even ulcerated haemangioma .
infantile haemangioma ( ih ) frequently requires no intervention . 
 eighty percent of ihs are focal and solitary . 
 fifteen percent of cutaneous haemangiomas occur on the extremities . a large size or a specific location or 
 both may carry complications such as ulceration which is one of the main complications , and active treatment is usually required to manage pain , potential scarring , and occasionally , bleeding and infection . 
 oral propanolol is used in the treatment of ih and is found to be an effective treatment for complicated ih , replacing systemic corticosteroids as first - line therapy . 
 recommendations for instituting treatment with propranolol in infants differ among different specialties and academic centres . 
 we report an infant with ulcerated ih of leg who responded dramatically to treatment with propranolol in 4 months .