the juvenile hemangioma ( jh ) is a form of capillary hemangioma which occurs during infancy at a rate of about 1 in every 200 live births . during the early stage it may resemble a common birthmark in that it is a flat , red lesion that intensifies in color when the infant strains or cries . with time it acquires an elevated , protruding appearance that distinguishes it from birthmarks and deeply situated lesions impart little color to the overlying skin and consequently may be misdiagnosed preoperatively . these tumors may be located on any body surface but are most common in the region of head and neck , particularly parotid , where they seemingly follow the distribution of cutaneous nerves and arteries . although described as congenital they actually appear within few weeks after birth and rapidly enlarge over a period of several months , achieving the largest size in about 6 - 12 months , after which they regress over a period of a few years . regression is usually accompanied by fading of the lesion from scarlet to dull red - gray and by concomitant wrinkling of the once - taut skin . it has been estimated that by age 7 years , 75 - 90% have involuted , leaving a small pigmented scar . in the lesions that have ulcerated early lesions are characterized by plump endothelial cells that line vascular spaces with small inconspicuous lumens . mast cells and factor - viii  positive interstitial cells are a consistent feature of these tumors . the former may be important in the production of angiogenic factors that regulate the growth of these tumors . at this early stage of development the vascular nature of the tumor may not be readily apparent unless a reticulin preparation is done that demonstrates connective tissue fibers encircling myriad tiny vessels . as the lesions mature and blood flow through the lesion commences , the endothelium becomes flattened and resembles that seen in adult forms of capillary hemangioma . regression of the jh is accompanied by a progressive , diffused interstitial fibrosis and is believed to be mediated by way of apoptosis . in unusual cases , a 3 year old male child was referred to the department of oral and maxillofacial surgery at nims dental college , jaipur , rajasthan , due to a painless , dome - shaped lesion of the upper lip , extending upto the cheek on the right side , light red in color , measuring 2  4 cm , present since 20 days after birth , when it first appeared . parents revealed that the lesion would change color to a deep red when the child cried . on intraoral examination the lesion , firm on palpation , was excised under local anesthesia , and the specimen was sent to the department of oral pathology , nims dental college , jaipur , rajasthan , for histopathological evaluation . five micrometer sections were made for staining with h and e and 3-m sections were made for immunohistochemical analysis for the traditional markers cd 34 and cd 31 . the immunohistochemical analysis was performed in the department of histopathology at santokba durlabhji memorial hospital , jaipur , rajasthan . the tissue received after excisional biopsy had a wrinkled surface [ figure 1 ] and revealed a cream colored , gelatinous cut surface [ figure 2 ] . the gross tissue appears small due to decrease in size after compression of the lesion to drain out the blood during and after performing excisional biopsy procedure . wrinkled surface of excised lesion cream - colored gelatinous cut surface sections stained with h and e were observed under 4 , 10 and 40 to reveal normal epithelium , under which was a band of normal connective tissue . the lobules contained plump endothelial cells lining vascular spaces with inconspicuous lumens [ figure 4 ] . some areas were more solid and organized containing a proliferation of endothelial cells [ figure 5 ] . on the basis of clinical and histopathological features , a diagnosis of jh was made . lesional area showing lobules below normal epithelium and connective tissue ( h and e , 4 ) plump endothelial cells lining vascular spaces with inconspicuous lumens ( h and e , 10 ) solid areas containing proliferation of endothelial cells ( h and e , 40 ) the sections were positive for cd 34 [ figure 6 ] and cd 31 [ figure 7 ] , which confirmed the diagnosis of our lesion which was in its proliferating phase in most regions of the neoplasm and involuting in a few areas . cd 34 expression in lesional areas ( 10 ) cd 31 expression in lesional areas ( 40 ) the tissue received after excisional biopsy had a wrinkled surface [ figure 1 ] and revealed a cream colored , gelatinous cut surface [ figure 2 ] . the gross tissue appears small due to decrease in size after compression of the lesion to drain out the blood during and after performing excisional biopsy procedure . sections stained with h and e were observed under 4 , 10 and 40 to reveal normal epithelium , under which was a band of normal connective tissue . the lobules contained plump endothelial cells lining vascular spaces with inconspicuous lumens [ figure 4 ] . some areas were more solid and organized containing a proliferation of endothelial cells [ figure 5 ] . on the basis of clinical and histopathological features , a diagnosis of jh was made . lesional area showing lobules below normal epithelium and connective tissue ( h and e , 4 ) plump endothelial cells lining vascular spaces with inconspicuous lumens ( h and e , 10 ) solid areas containing proliferation of endothelial cells ( h and e , 40 ) the sections were positive for cd 34 [ figure 6 ] and cd 31 [ figure 7 ] , which confirmed the diagnosis of our lesion which was in its proliferating phase in most regions of the neoplasm and involuting in a few areas . cd 34 expression in lesional areas ( 10 ) cd 31 expression in lesional areas ( 40 ) in our case the clinical and histopathological features suggest that the lesion was in the proliferating and involuting phase . the solid areas gave a clear indication that the lesion was a long - standing one . the clinical phases of jh have distinctive underlying physiological differences , which have been correlated with equally distinctive immunophenotypic profiles by takahashi et al . during the early proliferative phase ( 0 - 12 months ) the tumors can be shown immunohistochemically to express proliferating cell nuclear antigen ( pcna ) , vascular endothelial growth factor ( vegf ) , and type iv collagenase , the former two localized to both endothelium and pericytes , and the last to endothelium . all of these substances are associated with proliferation and growth of vessels . during the involuting phase ( 1 - 5 years ) these are dramatically reduced , whereas the tissue inhibitors of metalloproteinases ( timp ) , anti - angiogenic factors , are markedly elevated . the traditional vascular markers cd 31 , von willebrand factor ( vwf ) , and smooth muscle actin ( pericyte marker ) are present during the proliferating and involuting phases , but are lost after the lesion is fully involuted . jh also expresses glut1 , a glucose transport receptor , the expression of which is independent of proliferative activity , and is not found in other forms of hemangiomas although it is present rarely in angiosarcomas . this protein is also expressed by human placenta and has led to the novel hypothesis that the proliferative component of jh may be derived from embolized placental vascular cells . neonatal and infantile hemangiomas grow rapidly initially , but the majority spontaneously involute by age 7 years . surgical excision during the proliferative phase should be avoided due to risk of major blood loss and injury to facial nerve . diagnosis may be made by aspiration cytology and conservative nonoperative management includes steroids to reduce growth , compression therapy , or embolization . no treatment may be required , however , a small percentage of hemangiomas present themselves with indications for prompt therapy ( including surgical excision ) , such as severe disfigurement , airway compromise , excessive bleeding , and ophthalmological complication . the patient was examined after 2 months .