Ulcerated infantile hemangioma in the β-blocker era: recent advances

Whilst β-blockers have revolutionized the management of complicated infantile hemangiomas (IHs), ulceration remains a highly painful and clinically challenging complication. Ulcerated IHs may lead to pain, bleeding, secondary infection, feeding or diaper-care difficulties, functional impairment, and permanent scarring. Early recognition and integrated management are therefore essential.

This narrative review searched PubMed, Embase, and Cochrane Library databases from inception to June 2026 for studies concerning ulcerated IH. The search was restricted to publications written in English; relevant evidence was synthesized in a narrative fashion.

Ulceration is more likely to occur in rapidly proliferating, large, superficial, mixed, segmental, or partially segmental IHs. This is particularly so for those involving the lips, neck, diaper area, perineal or anogenital region, and skin folds. Early white discoloration is an important warning sign of impending ulceration. Current evidence suggests that ulceration should not be regarded merely as a surface wound but as a dynamic manifestation of active hemangioma proliferation, local tissue vulnerability, environmental barrier disruption, inflammation, and delayed wound repair. Oral propranolol remains the main systemic treatment, whereas wound care, pain control, infection surveillance, topical β-blockers, pulsed dye laser treatment, and individualized multimodal therapy may be needed according to ulcer severity and the anatomical site involved.

In the β-blocker era, ulcerated IH remains an important clinical problem requiring early risk stratification and integrated lesion-directed and wound-directed management. Future prospective multicenter and mechanistic studies are needed to standardize assessments of severity, refine risk-stratified treatment algorithms, and improve long-term functional and cosmetic outcomes for infants with ulcerated IHs.