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 hemangiomas 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 elevated 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 monozygotic and dizygotic twins found no significant difference between the two groups, suggesting that environmental factors may play a more substantial role [ 7 ] .

Most individuals experience regression without the necessity of intervention; however, around 10%, which can vary by site, may lead to significant complications that necessitate treatment. Complications associated with IH can be classified into several categories: life-threatening, obstructive, ulcerative, or disfiguring. Life-threatening complications encompass airway and hepatic IHs. Functional complications that obstruct essential structures or hinder functionality include periocular, nasal, labial, parotid, auricular, and breast IHs. Local complications typically result from ulceration or occur in areas that are cosmetically sensitive [ 8 ] .

Infantile hemangiomas (IHs) can be associated with several syndromes, particularly when large or segmental hemangiomas are present. These include PHACES syndrome, an acronym for Posterior fossa malformations, Hemangioma, Arterial anomalies, Cardiac defects, Eye abnormalities, and Sternal clefting or supraumbilical raphe. It is associated with large, segmental hemangiomas, particularly 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 malformations, and Renal anomalies. PELVIS syndrome [ 10 ] stands for Perineal Hemangioma, External genital malformations, Lipomyelomeningocele, Vesicorenal abnormalities, Imperforate anus, and Skin tag. SACRAL syndrome stands for Spinal dysraphism, Anogenital anomalies, Cutaneous hemangioma, Renal anomalies, and Angioma of Lumbosacral localization [ 11 ] .

The objective of our study was to analyze the demographic and clinical characteristics such as age at onset, clinical presentation, site, size, type (based on depth), and associated complications in patients who visited our hospital retrospectively and also to compare our data with those obtained from the literature.

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 ( Figures 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 hemangiomas were sessile (89%). Localized hemangiomas were the most common (78%), followed by multifocal (15%) and segmental (7%).

Amblyopia was noted exclusively in patients with periocular 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.

This retrospective cross-sectional observational study comprehensively analyzed the demographic and clinical characteristics of infantile hemangiomas of 500 patients. The findings reveal significant insights into the age at onset, clinical presentation, and associated complications of these vascular 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 hemangioma were identified than females (57.14% vs. 42.85%).

In our study, 50% of patients exhibited a precursor lesion 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 hospital 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 infants [ 15 ] . We also found a significant portion of preterm infants (25%) developing infantile hemangioma. This connection 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 infantile 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 consistent with the previous study done by Lydiawati et al., who also noted that macules were the most frequent skin lesions (35.36%), with about 28.13% of patients exhibiting a combination 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 monitoring 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 corroborates 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 timing 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 cm ² and 16% exceeding 5 cm ² , is consistent with the findings of the study done by Lydiawati et al. [ 17 ] , with 14.29% of IH in their study being ≥5 cm ² . The size of the lesion is an important factor to observe since it can determine the likelihood of the complications. The predominance of focal hemangiomas (87%), with 15% multifocal 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 discoloration, morphologically. This is in accordance with the existing literature by Sturb et al. [ 20 ] , who found that the most common presentation was superficial hemangiomas characterized 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 progression, raises important considerations for clinical practice. The growth patterns of hemangiomas can significantly influence management strategies, as rapid growth may necessitate early intervention to prevent complications [ 21 ] . The stable size observed in 12% of cases may suggest a subset of hemangiomas that can be monitored without immediate 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%), 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 hemangiomas due to their rapid proliferative phase and greater tissue 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 associated with amblyopia, observed in 100% of cases (10/10). This supports earlier studies by Haggstrom et al. and Frieden et al., who emphasized the importance of early ophthalmologic 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, ideally 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.

In conclusion, our study provides a comprehensive analysis of the demographic and clinical characteristics of infantile hemangiomas, contributing valuable data to the existing literature. The findings underscore the need for heightened awareness among healthcare providers regarding the presentation and management of IH, particularly in vulnerable populations. Future research should focus on longitudinal studies to better understand the long-term outcomes of IH and the impact of early intervention on associated complications.