Huntington Beach, CA – Julie, M.D., says there is growing evidence that the use of topical timolol in the treatment of pyogenic granuloma (PG) may save children from undergoing surgery, especially if the PG is small and located on the face.
PG is a common benign vascular tumor that often occurs in children under 5 years of age and “usually occurs in very inconvenient areas, such as the cheeks,” said Dhossche, MD, a pediatric dermatologist at Oregon Health & Science University (OHSU) in Portland, Oregon, at the annual meeting of the Pacific Academy of Dermatology. “It can bleed profusely. Often, parents will take their child to the emergency room to treat bleeding that can’t be stopped. Our first-line treatment is usually surgery: scraping, electrocautery or excision.”
Several case reports on the use of topical forms of timolol (a non-selective beta-adrenergic antagonist) for the treatment of PG have been published in the medical literature, including a case series of seven patients (six of whom were treated with topical timolol). The authors of the case series hypothesized that beta-blockers might be effective in PG by causing vasoconstriction to stop bleeding.
In addition, Dhossche and colleagues retrospectively evaluated 92 children with a mean age of 4.5 years who received topical timolol for PG at Oregon Health & Science University between 2010 and 2020. The findings were presented in an abstract at the 2022 Pediatric Dermatology Research Consortium Annual Meeting.
At the initial visit, 80 of the 92 children (87%) received timolol only, 6 of the 92 (6.5%) received surgery, and 6 of the 92 (6.5%) received timolol and surgery. Of the 80 patients treated with timolol monotherapy, 42 (52.5%) were spared surgical intervention, the researchers observed. “So we’ve had some success with that,” she said. “It can also help with bleeding if you are waiting for surgery.”
Surgery may still be needed
For PG, she applies a drop of timolol to a lesion that has been closed with DuoDERM or a similar dressing, and repeats every 1-3 days, depending on how long the dressing stays in place. “This treatment may take 3-4 months to resolve,” she says.
If topical timolol doesn’t stop the PG bleeding, or if parents opt for surgical removal, then “some tears [during removal of the lesion] may be unavoidable,” Dhossche says. “My goal is to make the procedure as good an experience as possible by helping to calm nerves by being confident, smiling, prepping with topical lidocaine for 20-30 minutes, icing, and building an alliance with the parent,” knowing that if that doesn’t work, I may need the I knew that if that didn’t work, I might need the help of a pediatric sedation colleague,” she says.
When describing to children what will happen during the procedure, she continues, the choice of language is important. For example, instead of saying, “It feels like I’ve been stung by a bee,” say, “Some kids say it feels uncomfortable like they’ve been pinched, while others say it doesn’t feel that bad.” And, when describing the size of a needle or incision, instead of saying “it’s as big as…,” say “it’s as small as…”.
As described in a 2020 paper published in Pediatric Dermatology, it’s also important to keep children in the proper comfortable position when performing dermatology procedures in the clinic, which may include allowing a parent or caregiver to hug the child while the PG is removed, Dhossche said. “You want to try to distract the patient while performing the procedure,” she added. “That’s when you should pull out your iPhone, iPad, or ask for help from a certified child life specialist, if your facility has one.”
When she injects a child, “I’m not going to lie, but I’ll hide the needle if possible,” she says. “I would say, ‘You’re going to feel a sting.’ A vibrating tool helps when injecting.” She showed a picture of a vibrating light-up children’s toothbrush she found on Amazon for $10, “which works for me. It also relieves tension.”