Objective: To evaluate the relationship between early white discoloration of infantile hemangioma (IH) and ulceration. Design: Retrospective cohort study. Setting: Tertiary referral center. Patients: A case series of 11 infants with early white discoloration of IH are described. An additional 55 infants with IH, aged 3 months, were evaluated retrospectively from a photograph archive to further explore the relationship between early white discoloration and presence or development of ulceration. Main Outcome Measures: Patient demographics and hemangioma size, location, and subtype are documented. Sensitivity and specificity of white discoloration in relationship to ulceration are estimated. Results: Ten of the 11 infants in the case series were girls (90%); all IHswere of segmental or indeterminate subtype. Average age at first ulceration was 2.6 months, with average age at healing 5.2 months. No intervention halted progression of ulceration. Of the 55 additional 3-month-old infants, 14 had white discoloration and 12 of these 14 had or developed ulceration (86%). When the hemangioma was either white or slightly white, sensitivity for predicting ulceration was 1.00 (95% confidence interval [CI], 0.78-1.00), with a specificity of 0.68 (95% CI, 0.51-0.81). In contrast, in infants with either slightly white or no white discoloration, the sensitivity for not developing ulceration was 0.80 (95% CI, 0.52-0.96), with a specificity of 0.95 (95% CI, 0.83-0.99), suggesting that a lack of substantial white discoloration early in infancy indicates low risk of ulceration. Conclusion: Early white discoloration of infantile hemangioma is highly suggestive of impending ulceration.