Dear Editor,

We read with great interest the recent publication by Wang et al. [1] entitled, “The Efficacy and Safety of Topical β-Blockers in Treating Infantile Hemangiomas: A Meta-Analysis Including 11 Randomized Controlled Trials,” published in the October 2020 issue of Dermatology. This aim of the study was to evaluate current knowledge on topical β-blockers in treating infantile hemangiomas [1]. We appreciate the authors’ efforts to comprehensively analyze all existing data on the management of infantile hemangiomas in one paper. However, we wish to share a few opinions.

In Figure 4, the authors mention the efficacy of topical β-blockers compared with other interventions (placebo, corticosteroids, or pulsed dye laser) in treating superficial infantile hemangiomas. Topical β-blockers had significant higher efficacy than the other interventions did. However, we noticed some mistakes in Table 1 regarding data extraction. In the study of Danarti et al., the actual efficacy number in the 0.5% topical timolol maleate gel group was 30 [2]. The authors seem to have accidentally combined the numbers for the 0.5% topical timolol maleate gel group and the 0.5% topical timolol maleate solution group, resulting in an erroneously high efficacy number of 59 and leading to an increased risk ratio (RR).

Therefore, we adjusted the forest plot by replacing the efficacy number in the topical β-blockers versus corticosteroids subgroup and using random-effects models because there was a distribution of effect sizes and different studies estimate different intervention effects [3, 4] (Fig. 1). The difference in efficacy was significant between topical β-blockers and placebo (RR 5.21, 95% confidence interval [CI] 1.28–21.21, p = 0.02) and between topical β-blockers and pulsed dye laser treatment (RR 2.14, 95% CI: 1.06–4.34, p = 0.03). However, no significant difference in efficacy was observed between topical β-blockers and corticosteroids (RR 1.06, 95% CI: 0.69–1.62, p = 0.79). The overall efficacy of topical β-blockers was not significantly different from other interventions (RR 1.86, 95% CI: 0.85–4.09, p = 0.12). The heterogeneity is substantial (I2 = 69%).

Forest plot of the efficacy of topical β-blockers compared with other interventions (placebo, corticosteroids, or pulsed dye laser) in treating SIH. SIH, superficial infantile hemangioma.

Accordingly, the results reveal topical β-blockers may not be superior to all other interventions. However, the study was limited by small sample sizes, variable interventions, and differing outcome measurements. More extensive and rigorous randomized control trials could be helpful to understand the efficacy of different interventions.

Topical β-blockers may not provide better treatment efficacy than other interventions in infantile hemangioma.

The authors have no conflicts of interest to declare.

This research received no specific grant from any funding agency, commercial, or nonprofit organization.

M.-Y.S. and C.C. wrote the letter to the editor, critically revised it, and approved the submitted version.

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