Sir,

We read with interest the paper by Spiteri Cornish and Reddy entitled ‘The use of propranolol in the management of periocular capillary haemangioma – a systematic review.’1 The authors provide an excellent review regarding the changing paradigms for the management of patients with infantile haemangiomas (IHs) and provide clear evidence as to the effectiveness of propanolol. The authors were unable to find an RCT comparing propanolol with a recognised standard or a placebo and concluded that an RCT would be beneficial but difficult to perform. The primary reason being that clinical equipoise cannot be met; given the weight of recent evidence the majority of clinicians would now be reluctant to revert to previous treatments for IHs, and therefore cannot ethically choose at random which treatment to provide.2 An RCT in this situation will have inherent flaws with confounding factors and bias.

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