Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2025;15(4):5515 1 Unveiling Infantile Hemangiomas: A Comprehensive Study of Patterns, Presentations, and Complications Prashansa Jaiswal1, Jyoti Singh1, Aishwarya Dua2, Aaditya Sirohi3, Febin Ashraf1 1 Department of Dermatology, All India Institute of Medical Sciences, Bhopal, India 2 Skin lab by Dr Jamuna Pai, Greater Kailash-2, New Delhi, India 3 Department of CTVS, All India Institute of Medical Sciences, Bhopal, India Key words: Infantile hemangiomas, Clinical patterns, Presentations, Pediatric complications, Morphology Citation: Jaiswal P, Singh J, Dua A, Sirohi A, Ashraf F. Unveiling Infantile Hemangiomas: A Comprehensive Study of Patterns, Presentations, and Complications. Dermatol Pract Concept. 2025;15(4):5515. DOI: https://doi.org/10.5826/dpc.1504a5515 Accepted: July 1, 2025; Published: October 2025 Copyright: ©2025 Jaiswal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Jyoti Singh, MBBS, MD (DVL). Department of Dermatology, All India Institute of Medical Sciences, C-214, Emerald Park city, Bagh Sewaniya, Bhopal, Madhya Pradesh, 462026. ORCID No : 0009-0000-9327-6476. E-mail: jyotisingh1590@gmail.com Background: Infantile hemangioma is the most common vascular tumor in infants, affecting 4% to 10% of this population. It typically appears as a solitary cutaneous hemangioma but can also be multifocal or segmental. The condition progresses through rapid growth, a plateau phase, and gradual involution. Key risk factors include low birth weight, prematurity, female sex, multiple gestations, and family history. Clinical presentation varies among individuals. Objective: This study aimed to analyze the clinical characteristics of patients with infantile heman- gioma at our hospital, focusing on age at onset, presentation, location, size, type, and complications. Methods: A retrospective analysis of medical records of infants diagnosed with infantile hemangioma was conducted. Data were collected for statistical analysis on demographics, lesion characteristics, and complications. Results: The study reviewed 694 hemangiomas in 500 patients, with 50% having a precursor lesion at birth. A significant female predominance (72%) was noted, with most patients (72%) delivered at term. The strawberry mass was the most common morphology (74%), primarily located in the head and neck (42%). Of the hemangiomas, 45% were superficial, and 88% showed progressive growth. Ten patients with periocular hemangiomas experienced amblyopia, while other complications includ- ed PHACES syndrome, ipsilateral breast hypertrophy, and arteriovenous malformations. Conclusion: This study highlights the diverse manifestations, anomalies, and risk factors associated with infantile hemangioma in a tertiary care setting. ABSTRACT 2 Original Article | Dermatol Pract Concept. 2025;15(4):5515 Introduction Infantile hemangiomas (IH) represent the most frequently observed benign tumors in infants, with an incidence rate ranging from 4% to 10% [1]. These tumors originate from a benign proliferation of vascular endothelial cells (VECs) within the mesoderm and can manifest anywhere on the body [2]. The natural progression of infantile hemangio- mas is characterized by a triphasic pattern, which includes a rapid growth phase, a plateau phase, and a subsequent slow involution phase. This distinct progression differentiates them from vascular malformations [3]. Nonetheless, certain severe cases of proliferative IH may lead to functional or organic complications such as bleeding, infections, ulcers, external ear obstruction, and airway obstruction [4]. While IH is typically not present at birth, approximately one third of cases can be detected at that time. In 40% of instances, the tumor appears early in infancy, specifically between two to seven weeks of age, while the remaining third develops by six months of age [5]. The proliferation phase lasts from four to 18 months, followed by a gradual involution over three to nine years, often resulting in a fibrofatty remnant in 50% to 70% of cases, along with telangiectasia and excess skin. Key risk factors for IH include female sex, prematurity, low birth weight, European ancestry, multiple gestations, maternal progesterone therapy, and a family history of the condition [4]. Various antenatal factors have also been linked to an ele- vated risk of IH, including maternal vaginal bleeding during the first trimester, progesterone use, preeclampsia, advanced maternal age, placenta previa, and in vitro fertilization [6]. In contrast, a study examining the incidence of IH in monozy- gotic and dizygotic twins found no significant difference be- tween the two groups, suggesting that environmental factors may play a more substantial role [7]. Most individuals experience regression without the ne- cessity of intervention; however, around 10%, which can vary by site, may lead to significant complications that ne- cessitate treatment. Complications associated with IH can be classified into several categories: life-threatening, ob- structive, ulcerative, or disfiguring. Life-threatening com- plications encompass airway and hepatic IHs. Functional complications that obstruct essential structures or hinder functionality include periocular, nasal, labial, parotid, au- ricular, and breast IHs. Local complications typically result from ulceration or occur in areas that are cosmetically sen- sitive [8]. Infantile hemangiomas (IHs) can be associated with several syndromes, particularly when large or segmental hemangiomas are present. These include PHACES syn- drome, an acronym for Posterior fossa malformations, Hemangioma, Arterial anomalies, Cardiac defects, Eye ab- normalities, and Sternal clefting or supraumbilical raphe. It is associated with large, segmental hemangiomas, par- ticularly those on the face and neck [9]. Other syndromes involving the lower body are LUMBAR, PELVIS and SACRAL syndrome [2]. LUMBAR stands for lower body hemangioma and other cutaneous defects, Urogenital anomalies, Myelopathy, Bony deformities, Anorectal mal- formations, and Renal anomalies. PELVIS syndrome [10] stands for Perineal Hemangioma, External genital malfor- mations, Lipomyelomeningocele, Vesicorenal abnormali- ties, Imperforate anus, and Skin tag. SACRAL syndrome stands for Spinal dysraphism, Anogenital anomalies, Cu- taneous hemangioma, Renal anomalies, and Angioma of Lumbosacral localization [11]. Objective The objective of our study was to analyze the demographic and clinical characteristics such as age at onset, clinical pre- sentation, site, size, type (based on depth), and associated complications in patients who visited our hospital retro- spectively and also to compare our data with those obtained from the literature. Materials and Methods Study Design This hospital-based retrospective observational cross- sectional study was conducted in the Department of Der- matology at a tertiary care pediatric hospital. The study reviewed medical records of patients with infantile hemangi- omas (IH) treated in the outpatient clinic. Study Population The study population comprised patients aged less than 6 years at the time of enrollment who presented with one or more infantile hemangiomas at any stage of evolution. Inclu- sion criteria involved all patients with clinically diagnosed hemangiomas regardless of size, number, or anatomical lo- cation. Patients with other types of vascular anomalies were excluded. Sample Size A total of 500 patients were enrolled, and 694 hemangiomas were documented and analyzed. Study Period The data were collected retrospectively from medical records from the years 2013 to 2023 Data collected included demographic details, birth his- tory, age at onset, lesion characteristics, and any associated complications. Original Article | Dermatol Pract Concept. 2025;15(4):5515 3 The primary variables measured included: • Age at onset and presentation of the hemangiomas • Lesion characteristics: morphology (papule, macule, plaque, nodule), site (head and neck, trunk, genitalia, limbs, mucosal involvement), size, and number of hemangiomas • Progression of hemangiomas: gradual, rapid, or stable • Complications: ulceration, erythema, soft tissue hypertro- phy, bleeding, and associations like PHACES syndrome and amblyopia • Birth history: term or preterm delivery and birth weight • Associated conditions: amblyopia, PHACES syndrome, and arterio-venous malformations All clinical assessments were conducted in the outpatient dermatology department by dermatologists trained in pediatric dermatology. Initial evaluations were performed by one of three senior consultants, and data were retrospectively extracted from their standardized clinical documentation. To ensure con- sistency in diagnosis, a departmental protocol was followed for classifying hemangiomas based on established dermatological descriptors such as lesion depth (superficial, deep, mixed) and morphology (e.g., strawberry vs. bluish lesions). In cases where classification was ambiguous, diagnostic decisions were refined through consensus discussions held during routine departmental clinical meetings. Although ef- forts were made to maintain uniformity, we acknowledge that no formal inter-rater reliability testing or use of stan- dardized diagnostic checklists was undertaken, given the ret- rospective nature of the study. In patients with large segmental facial hemangiomas, evaluation for PHACES syndrome was guided by the 2009 consensus criteria by Metry et al. [12] Screening investi- gations included MRI/MRA of the brain and neck, echo- cardiography, and ophthalmologic examination. PHACES syndrome was diagnosed when a segmental facial heman- gioma >5 cm was accompanied by one major or two mi- nor anomalies across the defined domains. Genetic testing and multidisciplinary review were not routinely employed Statistical Analysis Data were analyzed using software SPSS 28.0.1. Descriptive statistics were used to summarize demographic data and clini- cal features. Categorical variables are expressed as frequencies and percentages, while continuous variables are summarized using means or medians as appropriate. Associations between variables were evaluated using chi-square tests or Fisher’s exact test. A p-value of <0.05 was considered statistically significant. Results A total of 694 hemangiomas were observed in 500 patients recruited from Out Patient Department In 50% (250) of patients, their guardians reported a precursor lesion presenting at birth, while in 46 % (230) of patients, the precursor lesion appeared by three months of age. In the remaining 4% (20), lesions appeared by six months of age at the latest. The majority (44%) of patients presented to the hospital within three months of developing lesions (Fig- ures 1–2). In our study population, most of the patients 72% (N=360) were born at term, while 25% (N=125) were preterm. Of the 500 patients recruited, 72% (N=360) were females, and the remaining 28% (N=140) were males (Figure 3). Twenty-three percent (N=115) of newborns had low birth weight. In majority of the patients, the precursor lesion was papule (56%), followed by macule (34%), plaque (6%), nodule (4%). Head and neck were found to be most common sites (42%), followed by the trunk (15%), genitalia (11%), upper limb (10%), lower limb (7%), and mucosa (5%). Multiple sites were involved in 7% patients (Figure 4). Forety-four percent (N=305) of hemangiomas ranged in size from 2–5 cm, while 40% (N=277) hemangiomas were <2 cm. Large hemangiomas (>5 cm) were seen in 16% (N=111) of patients. Majority of the patients (87%, N=435) had a solitary hemangioma. Two percent (N=10) of patients had >5 hemangiomas (Figure 5). The most common morphology observed was strawberry mass (74%, N=514 lesions); bluish discoloration was seen in 28% (N=194) of patients. Twenty-eight percent (N=194) of lesions were ulcerated. On stratified analysis, ulceration was most commonly observed in mixed-type hemangiomas (45.9%, 118/257), compared to superficial (20%, 62/312) and deep (13.6%, 17/125) lesions. Anatomically, facial hemangiomas had the highest incidence of ulceration (31%, 91/294), followed by extremities (28%, 50/180) and trunk (22%, 23/105) (Figure 6). Erythema was seen in 17% (118) of hemangiomas. Associated soft tissue hypertrophy was seen in 12% (N=83) of patients, while bleeding was present in 6% (N=42). Out of 694 hemangiomas, 45% were superficial (N=312), 18% were deep (N=125), and 37% (N=257) were mixed hemangiomas. The majority of hemangio- mas were sessile (89%). Localized hemangiomas were the most common (78%), followed by multifocal (15%) and segmental (7%). Amblyopia was noted exclusively in patients with perio- cular hemangiomas, affecting 10 out of 25 patients. On detailed examination, three patients with large segmental hemangiomas over the face were found to have PHACES syndrome. Three patients had associated arterio-venous malformation. A single patient with hemangioma over the chest had associated ipsilateral breast hypertrophy. 4 Original Article | Dermatol Pract Concept. 2025;15(4):5515 Figure 1. Clinical pictures of IH patients showing varied clinical presentations. Figure 3. Showing sex distribution: Female (72%) (Blue) vs Male (28%) Red. Figure 2. Age at presentation of precursor lesions of infantile hemangioma in the study. Original Article | Dermatol Pract Concept. 2025;15(4):5515 5 Figure 4. Anatomical sites of distribution of infantile hemangioma found in the study. Figure 5. Size distribution of infantile hemangioma in the study. Figure 6. A bar chart showing ulceration rates across lesion types and anatomical locations. Discussion This retrospective cross-sectional observational study com- prehensively analyzed the demographic and clinical char- acteristics of infantile hemangiomas of 500 patients. The findings reveal significant insights into the age at onset, clin- ical presentation, and associated complications of these vas- cular lesions, contributing to the existing literature on this prevalent condition. Our findings reveal a predominance of female patients (72%) ,which is consistent with the findings of the  study done by Munden et al. [3], with 53% of  female and 47% of male infants presenting with infantile hemangioma. This sex bias is likely influenced by hormonal factors, although the exact mechanisms remain unclear. However in a study done by Sandru et al. [13], more male patients with heman- gioma were identified than females (57.14% vs. 42.85%). In our study, 50% of patients exhibited a precursor le- sion at birth, while 46% developed the lesion by age three months. This finding is consistent with findings from a prior study done by Chang et al. that highlighted the early onset of infantile hemangiomas by three months of age, indicating a crucial period for observation and possible intervention [14]. Furthermore, in our study, 44% of patients sought hos- pital care within three months of lesion appearance, which emphasizes the urgency often felt by caregivers regarding these vascular anomalies. This finding is also consistent with the finding from Chang et al., where the mean age at the first visit was five months. The correlation between infantile hemangiomas (IH) and prematurity has been extensively established, with numerous studies demonstrating a greater occurrence of IH in preterm infants relative to those born at term. One such study is by Suzen Orhan et al., who found IH in 26.6% of preterm in- fants [15]. We also found a significant portion of preterm infants (25%) developing infantile hemangioma. This con- nection is believed to arise from common pathophysiological processes, especially those related to hypoxia and vascular growth factors. The case-control study done by Chehad et al. [16], on clinical and epidemiological risk factors for infantile hemangioma indicates that the occurrence of infan- tile hemangioma (IH) is significantly elevated in low birth weight (LBW) infants, with odds ratios suggesting a 4.5-fold increased risk for LBW infants in comparison to those of normal weight. This finding is congruous with our study, where a significant 23% of newborns with low birth weight developed IH. In our study, most patients (56%) with IH presented with papule as precursor lesion, followed by macules (34%), plaques (6%), and nodules (4%). These findings are consis- tent with the previous study done by Lydiawati et al., who also noted that macules were the most frequent skin lesions 6 Original Article | Dermatol Pract Concept. 2025;15(4):5515 followed by superficial (20%) and deep lesions (13.6%). This aligns with the findings of Mariani et al., who reported increased complication rates in mixed and larger hemangi- omas due to their rapid proliferative phase and greater tis- sue involvement, which can predispose to breakdown and ulceration [8]. Among anatomical sites, facial lesions showed the highest ulceration rate (31%), consistent with a study by Chang et al. highlighting that hemangiomas in exposed or high-motion areas (such as the face and extremities) are at higher risk of mechanical irritation and breakdown [14]. Moreover, periocular hemangiomas were strongly asso- ciated with amblyopia, observed in 100% of cases (10/10). This supports earlier studies by Haggstrom et al. and Frie- den et al., who emphasized the importance of early ophthal- mologic evaluation in infants with periocular hemangiomas due to the risk of visual axis obstruction, astigmatism, and anisometropia [22,23]. Our findings reinforce the need for clinicians to monitor mixed-type and facial hemangiomas closely for early signs of ulceration and to promptly refer periocular hemangiomas for ophthalmologic evaluation, ide- ally within the first few weeks of life. Additionally, we observed associations with syndromic conditions such as PHACES syndrome and arteriovenous malformations in three patients, along with ipsilateral breast hypertrophy noted in one patient with infantile hemangioma located on the chest. These findings echo the concerns raised in a previous study done by Haggstrom et al. regarding the potential for IH to be associated with significant morbidity, particularly when located in critical areas [23]. The incidence of ulceration (28%) and bleeding (6%), which corroborate the findings of Sun et al. [18], further emphasizes the need for comprehensive management strategies to address both the aesthetic and functional implications of IH. Limitations This study has several limitations inherent to its retrospective design. First, no a priori power calculation was performed. The sample size of 500 patients was based on feasibility and represents a consecutive cohort over a 10-year period at a single tertiary care center. While adequate for descriptive analysis, the study is likely underpowered to detect statis- tically significant associations for rare outcomes such as PHACES syndrome or amblyopia. A post hoc estimate sug- gests a larger sample size would be required to detect these events reliably. Future studies should incorporate prospec- tive power planning. Second, the referral bias associated with conducting the study at a tertiary care pediatric hospital may have led to an overrepresentation of severe, atypical, or treatment-resistant infantile hemangiomas. This could limit the generalizability of findings to general pediatric or primary care settings. We recommend that future research include community-based (35.36%), with about 28.13% of patients exhibiting a com- bination of macular and nodular lesions [17]. These findings suggest that the majority of cases begin with a papular stage, highlighting the importance of early recognition and moni- toring of these precursor lesions in infants. Head and neck were found to be the most common sites (42%), followed by the trunk (15%), genitalia (11%), upper limb (10%), lower limb (7%), and mucosa (5%). Multiple sites were involved in 7% of patients in our study. This cor- roborates with the study by Otaibi et al., who found that the most common site of hemangioma was the face (36.4%), followed by the upper limbs (18.3%), lower limbs (12.7%), chest (12.7%), and scalp (9.1%). The site preference could be justified by the anatomical factors as well as by the tim- ing of vasculature development of different sites. It has been found that the head and neck are the most common sites as they have a higher density of blood vessels, making them more susceptible to vascular tumors like IH. It can also be seen that IHs typically manifests within the first few weeks of life, which coincide with the rapid vascular development in the head and neck areas [18]. The size distribution of hemangiomas in our study, with 44% ranging from 2–5 cm2 and 16% exceeding 5 cm2, is consistent with the findings of the study done by Lydiawati et al. [17], with 14.29% of IH in their study being ≥5 cm2. The size of the lesion is an important factor to observe since it can determine the likelihood of the complications. The pre- dominance of focal hemangiomas (87%), with 15% multifo- cal and 7% segmental in our study, is in accordance with the findings from the study done by Hung et al.[19] and Chiller et al.[5].In this study we observed that 45% of lesions were superficial (N=312) and 18% lesions were deep (N=125); 37% (N=257) were mixed hemangiomas, among which 74% were strawberry mass and 28% were bluish discolor- ation, morphologically. This is in accordance with the exist- ing literature by Sturb et al.[20], who found that the most common presentation was superficial hemangiomas charac- terized by bright red or “strawberry mass” that involves the upper dermis. While deep lesions have a more bluish hue, mixed lesions have both characteristics. The observation that 88% of hemangiomas exhibited progressive growth, with a notable 40% showing rapid pro- gression, raises important considerations for clinical prac- tice. The growth patterns of hemangiomas can significantly influence management strategies, as rapid growth may ne- cessitate early intervention to prevent complications [21]. The stable size observed in 12% of cases may suggest a sub- set of hemangiomas that can be monitored without immedi- ate treatment, emphasizing the importance of individualized patient assessment. Our post hoc stratified analysis revealed that mixed-type hemangiomas had the highest rate of ulceration (45.9%), Original Article | Dermatol Pract Concept. 2025;15(4):5515 7 5. Chiller KG, Passaro D, Frieden IJ. Hemangiomas of infancy: clin- ical characteristics, morphologic subtypes, and their relationship to race, ethnicity, and sex. Arch Dermatol. 2002;138:1567–1576. DOI:10.1001/archderm.138.12.1567 | PMID:12472344. 6. 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Evidence-Based populations or birth cohorts to provide a more representa- tive epidemiological profile of infantile hemangiomas across clinical contexts. Third, while lesion assessments were performed by derma- tologists following a standardized departmental protocol, eval- uations were conducted by multiple providers over the study period. Although diagnostic classification relied on established morphological descriptors and consensus discussions were held for ambiguous cases, we acknowledge that no formal inter-rater reliability testing or structured diagnostic checklist was used. This introduces the potential for inter-observer vari- ability in lesion classification and complication reporting. Lastly, due to the retrospective nature of the study, imag- ing and diagnostic protocols (e.g., MRI, echocardiography for PHACES syndrome) were selectively applied to patients with clinical indications (e.g., large segmental facial heman- giomas). 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