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demonstrating its efficacy and side effects&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Materials and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">Forty-six infants treated between August 2016 and March 2018 were included from two National Institutes of Pediatric Health in Lima&#44; Peru&#46; All IH required treatment for functional risk&#44; cosmetic disfigurement&#44; and lack of response to prior treatments or side effects due to propranolol&#46; This study was not assessed by and ethical committee review&#46; The parents of the patients received information about the effects and side effects of the treatment and gave their consent before starting treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figs&#46; 1</a>&#8211;<a class="elsevierStyleCrossRef" href="#fig0010">2</a>&#41;&#46; Physical examination&#44; baseline electrocardiogram and a pediatric cardiologist evaluation were required for all patients started on atenolol&#46; During follow-up heart rate and blood pressure were registered in every visit&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Treatment with oral atenolol 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg in a daily dose was indicated in all patients in an outpatient environment&#46; Atenolol dosage was adjusted according to weight gain in every monthly control and if inadequate response was observed&#44; the dosage was increased to a maximum of 3<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#46; Controls with photographic documentation at baseline&#44; 2 weeks and monthly until the end of treatment were performed&#46; Clinical involution was assessed in every control in the outpatient clinic evaluating color change&#44; softening upon palpation and size reduction supported by clinical photographs&#46; Treatment outcome was determined as complete involution&#59; &#40;presence of telangiectasia or residual fibroadipose tissue&#41;&#44; partial regression and no response&#46; Side effects were recorded in every visit&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">The study consisted of 46 infants&#44; 35&#47;46 &#40;76&#44;1 &#37;&#41; females and 11&#47;46 &#40;23&#44;9 &#37;&#41; males presenting with a total of 55 IH&#46; Sixty-one percent &#40;61&#44;8 &#37;&#41; of IH were located in the head and neck area&#44; 16&#44;4 &#37; extremities&#44; 14&#44;5 &#37; genitals and 7&#44;3 &#37; trunk&#46; By type&#44; 60 &#37; of IH were superficial&#44; 32&#44;7 &#37; mixed and 7&#44;3 &#37; deep&#46; Of all IH&#44; 12&#44;7 &#37; presented ulceration&#46; Four patients in our series had undergone treatment with propranolol suspended on account of side effects&#46; The mean age at the start of the treatment with atenolol was 4&#44;35 months &#40;range of age between 1 and 34 months&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Treatment duration lasted on average 6&#44;4 months &#40;range 4&#8211;17 months&#41;&#46; All patients responded to the treatment with oral atenolol&#46; Complete involution in 61&#44;8 &#37; and partial regression in 38&#44;2 &#37; of patients was observed&#46; Ulcerated IH presented complete wound closure at a mean time of 16&#44;4 days &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; No recurrence was observed after discontinuation of treatment&#46; Twenty-three percent &#40;23&#44;9 &#37;&#41; of patients presented mild side effects&#46; The main side effect reported was limited to mild transient diarrhea&#46; Only one patient presented mild sleep disturbance at the start of treatment with spontaneous resolution&#46; No adverse events such as hypoglycemia&#44; bronchospasm&#44; bradycardia&#44; or hypotension were reported&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Since its FDA approval in 2014&#44; propranolol&#44; a lipophilic&#44; non-selective beta-adrenergic blocker&#44; remains the mainstay treatment for IH&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> However&#44; propranolol rarely may present undesired side effects and thus the interest for alternatives with similar efficacy have been considered recently&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Atenolol is a hydrophilic&#44; selective beta-1 blocker and its mechanism of action on IH is currently unknown&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> Several advantages in comparison with propranolol however have been observed&#46; First&#44; by avoiding beta-2 receptors&#44; bronchial hyperreactivity and hypoglycemia are avoided&#46; Second&#44; its hydrophilic property reduces the passage to the blood brain barrier and consequently reduces sleep disturbances&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Atenolol is also administered once daily and therefore provides a better patient adherence to the medication&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Previously&#44; the only randomized comparative study of atenolol versus propranolol&#44; demonstrated similar efficacy with fewer side effects in regards with respiratory bronchospasm&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Subsequent studies have sustained similar consistency with these results&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;7&#44;8</span></a> In our case series&#44; we achieved to demonstrate great results with atenolol while no adverse side effects were noted&#46; Another interesting result is the rapid response in the seven ulcerated IH with atenolol&#46; Although it is a small subgroup of our treated IH&#44; comparatively a previous study showed on average 8 weeks fo full healing of the wound&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> All our ulcerated IH were additionally indicated zinc sulfate 1 &#37; &#40;15<span class="elsevierStyleHsp" style=""></span>ml in 50<span class="elsevierStyleHsp" style=""></span>ml of water&#41; 2 times daily as topical cures&#44; until complete epithelization was achieved&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusion</span><p id="par0040" class="elsevierStylePara elsevierViewall">We present a non-randomised&#44; non-blinded case series of 46 patients with IH treated successfully with oral atenolol&#46; Our findings are based on clinical observations&#46; Taking into account these limitations&#44; oral atenolol has proved to be an effective and safe alternative for problematic IH&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">We propose atenolol as a possible first line treatment&#46; Even though our study has its limitations&#44; it serves to provide further clinical evidence for future formal comparative studies to assess the effectiveness of atenolol versus propranolol to verify our findings&#46;</p></span></span>"
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            0 => "Vascular anomalies"
            1 => "Vascular tumors"
            2 => "Infantile hemangioma"
            3 => "Atenolol"
            4 => "Propranolol"
            5 => "Beta-Blockers"
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            3 => "Atenolol"
            4 => "Propranolol"
            5 => "Tratamiento sist&#233;mico"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Propranolol a non-selective beta-blocker&#44; remains the first line of treatment for problematic infantile hemangioma&#46; However&#44; although rarely&#44; a subset of patients experience undesirable side effects&#44; raising interest in other selective beta-blockers&#46; We present a large case series of 46 infants treated successfully with oral atenolol&#44; a selective beta-1 blocker&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El propranolol&#44; un betabloqueante no selectivo&#44; sigue siendo la primera l&#237;nea de tratamiento para el hemangioma infantil problem&#225;tico&#46; Sin embargo&#44; aunque poco frecuente&#44; un subgrupo de pacientes experimenta efectos secundarios indeseables&#44; lo que despierta el inter&#233;s sobre otros beta-bloqueantes selectivos&#46; Presentamos una amplia serie de casos de 46 lactantes tratados con &#233;xito con atenolol&#44; un bloqueante selectivo beta 1&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Calder&#243;n-Castrat X&#46;&#44; Vel&#225;squez F&#46;&#44; Castro R&#46;&#44; Ballona R&#46; Atenolol oral en el manejo del hemangioma infantil&#58; serie de casos de 46 pacientes&#46; Actas Dermosifiliogr&#46; 2020&#59;111&#58;59&#8211;62&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical photographs of a 7-month-old girl with a mixed focal ulcerated IH of the major labia and two 4-month-old girls with a superficial focal ulcerated IH of the buttocks treated with oral atenolol showing changes in the color&#44; size and wound closure at baseline <span class="elsevierStyleBold">&#40;a&#44;e&#44; i&#41;&#44;</span> 2 weeks <span class="elsevierStyleBold">&#40;b&#44;f&#44;j</span>&#41;&#44; 4 months <span class="elsevierStyleBold">&#40;c&#44;g&#44;k&#41;&#44;</span> and 6 months <span class="elsevierStyleBold">&#40;d&#44;h&#44;l&#41;</span>&#46;</p>"
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                          "etal" => true
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