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Natural History The majority of hemangiomas appear within the first month of life but only a few are
present as fully formed tumors at birth.23 Precursor lesions, consisting of
erythematous macules, blanched areas or
Involution of a hemangioma is a slow process that generally begins after the first year
of life and is Thirty percent of hemangiomas will completely resolve by age three,
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localized telangiectasias with pale surrounding
halos, are present at birth in approximately half of all cases.24(Figure 3).
Rarely, skin ulceration is the first sign of a hemangioma.25 These initial
lesions progress through a stage of rapid growth and proliferation that lasts several
months but is generally completed by one year of age.6,26 Once the hemangioma
is fully mature there is a prolonged involutional phase that generally lasts 3-7 years.
The life cycle of rapid expansion followed by slow involution is highly characteristic of
hemangiomas and helps the clinician separate hemangiomas from other vascular lesions. Most
of the rapid growth of hemangiomas occurs in the first 6-10 months of life but late growth
can, in rare instances, persist into the second year of life. It is this rapid growth that
often frightens parents and referring physicians. 
accompanied by several clinical events. Cutaneous hemangiomas
gradually change from bright red to a dull purple or mottled gray-white color as
involution progresses (Figure 4).26 The lesion begins to soften and the
overlying skin becomes wrinkled. Ulceration, present in some hemangiomas, will cease and
spontaneously heal. Swelling of hemangiomas with crying or straining is not as common
during involution as it is during proliferation.26 
50%
by age five and 70-90% by age seven.6,26, 27 Almost all hemangiomas will
complete the involutional process by age 12 but not all hemangiomas will resolve.6,28
Some children are left with significant residual atrophy, wrinkling, telangiectasias,
hypopigmentation or cutaneous redundancy. In the most severe instances, rapid
proliferation damages cartilage, which results in a deformed ear or nose once involution
is complete (Figure 5). The rate and completeness of resolution of a hemangioma are
unrelated to sex, race, size or clinical appearance.6,29 There is evidence that
hemangiomas that are fully formed at birth undergo an accelerated involution.23
It has been shown that cutaneous (superficial) hemangiomas are just as likely to resolve
as subcutaneous (deep) lesions.6,29 Some evidence suggests that hemangiomas of
the tip of the nose, lip, and parotid area are slow to involute.6,7,30,31