IMPORTANCE: Although clinical practice guidelines exist for the treatment of infantile hemangiomas (IHs), recommendations are heterogeneous, and wide practice variations in IH management have been reported. OBJECTIVE: To analyze the degree of agreement in treatment choices for IH among pediatric dermatologists in North America and Europe and assess whether there are differences across IH risk categories. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional interrater and intrarater agreement study was conducted through a survey based on the Spanish Academy of Dermatology and Venereology IH prospective cohort. The survey used 50 vignettes of IH cases that were randomly selected from the cohort. It was administered twice in 2023, 1 month apart, to allow for interrater and intrarater agreement assessments. Data were analyzed in January 2024. The study involved pediatric dermatologists from North America (via the Pediatric Dermatology Research Alliance) and Europe (via the European Society of Pediatric Dermatologists). EXPOSURES: Participants were asked to choose 1 of 3 treatment options (propranolol, topical timolol, or observation) for each vignette. MAIN OUTCOME AND MEASURE: The primary outcome was the interrater agreement in treatment choices for IH cases, measured using κ statistics (Gwet AC1 coefficient). RESULTS: The global interobserver agreement among 90 pediatric dermatologists was fair (AC1, 0.38
95% CI, 0.29-0.46). In North America (45 pediatricians), agreement was moderate (AC1, 0.41
95% CI, 0.33-0.49), while in Europe (45 pediatricians) it was fair (AC1, 0.37
95% CI, 0.28-0.46). The degree of agreement varied depending on the risk category of IH, with excellent agreement in high-risk IH and only moderate agreement in intermediate-risk and low-risk IHs. Propranolol was predominantly chosen for high-risk IH, while observation was most frequent for low-risk IH (55.9%). The second survey had 61 respondents, with no significant intrarater differences. CONCLUSIONS AND RELEVANCE: The results of this survey study suggest that there is an important variability in the treatment of intermediate-risk and low-risk IH. The study findings support the need for more evidence regarding the role of topical timolol in IH treatment, which may help harmonize treatment approaches and improve consistency in IH management globally.