Pyogenic Granuloma

Authored by Dr Laurence Knott, 30 Nov 2016

Reviewed by:
Dr Hannah Gronow, 30 Nov 2016

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Synonyms: lobular capillary haemangioma

Pyogenic granulomata are common benign vascular lesions of the skin and mucosa. They are not infective, purulent or granulomatous (as the name might suggest) - rather, a reactive inflammatory mass of blood vessels and a few fibroblasts within the dermis of the skin.

  • This is not fully understood: rapid growth occurs in response to an unknown stimulus that triggers endothelial proliferation and angiogenesis.
  • Trauma and burns can provoke the sequence but frequently there is no identifiable cause.
  • Bacterial infection may be involved. Staphylococcus aureus is often isolated from the lesion.
  • Other suggested causes include viral oncogenes, hormonal influences (pregnancy, oral contraceptive pill) and cytogenetic abnormalities.
  • They have also been associated with certain medications:
    • Systemic and topical retinoids[2, 3].
    • Indinavir (a protease inhibitor)[4].
    • Chemotherapy agents such as fluorouracil and paclitaxel[5, 6].
  • Mean age for presentation is 6-7 years. Thereafter, there is a decrease in incidence with age[7]. They represent 0.5% of skin nodules in children[8].
  • They are more common in women, due to frequent formation on the gingiva during pregnancy (pregnancy tumour, or epulis gravidarum) - occurring in up to 5% of pregnancies[9].
  • Solitary[10]red, purple or yellow papule or nodule arising from normal skin.
  • Size varies from a few millimetres in diameter to several centimetres.
  • Polypoid appearance - they often develop a stalk or 'collarette' of scale at the base.
  • Friable lesion - they are often seen to be bleeding, crusted or ulcerated.
PYOGENIC GRANULOMA -CLOSE UP TOP
PYOGENIC GRANULOMA -CLOSE UP SIDE
PYOGENIC GRANULOMA
  • Rapid eruption and growth over a few weeks.
  • Most commonly, they occur on the head, neck and extremities (particularly the fingers).
  • They occasionally occur on the external genitalia[11].
  • In pregnancy, they are most likely to occur on the maxillary intraoral mucosal surface during the second and third trimesters.
  • They have also been reported on the labial mucosa in men[12].
  • Rarely, multiple satellite lesions may develop - especially in adolescents and young adults after prior attempts to remove the original lesion.

Includes:

Some advocate sending all lesions for histological confirmation. This is because the vascular nature of the lesion makes dermoscopy unreliable[14]. However, there may be occasions on which dermoscopy may be considered sufficient (eg, typical appearance in a very young child)[15].

  • Most patients seek help because of the bleeding associated with the lesion.
  • Treatment options include curettage and cautery, shave excision, excision with primary closure and laser therapy.
  • Cryotherapy may work but does not provide a histological specimen for diagnosis.
  • One study reported the use of sclerotherapy employing sodium tetradecyl sulfate as the sclerosant. As with cryotherapy, this technique does not provide a histological specimen[16]. Moreover, sodium tetradecyl sulfate is only licensed for the treatment of varicose veins in the UK, so the usual considerations concerning the use of unlicensed medicines apply.
  • For assistance with diagnosis and removal.
  • Following a recurrence.
  • Where a nodular melanoma is suspected.

Pain and bleeding are the most usual problems associated with this lesion.

  • Pyogenic granulomata are benign lesions.
  • Untreated lesions will atrophy eventually but only a minority will spontaneously involute within six months.
  • Recurrence rates following treatment can be common regardless of treatment modality.
  • Pregnancy tumours tend to regress spontaneously following childbirth so treatment should be postponed accordingly.

Further reading and references

  • Kumar P, Das A, Mondal A, et al; Pyogenic granuloma-like basal cell carcinoma on the abdomen: A deceptive presentation. Indian Dermatol Online J. 2016 Sep-Oct7(5):446-448.

  1. Pyogenic Granuloma; DermNet NZ

  2. Badri T, Hawilo AM, Benmously R, et al; Acitretin-induced pyogenic granuloma. Acta Dermatovenerol Alp Panonica Adriat. 201120(4):217-8.

  3. Tinoco MP, Tamler C, Maciel G, et al; Pyoderma gangrenosum following isotretinoin therapy for acne nodulocystic. Int J Dermatol. 2008 Sep47(9):953-6. doi: 10.1111/j.1365-4632.2008.03662.x.

  4. Wollina U; Multiple eruptive periungual pyogenic granulomas during anti-CD20 monoclonal antibody therapy for rheumatoid arthritis. J Dermatol Case Rep. 2010 Dec 194(3):44-6. doi: 10.3315/jdcr.2010.1050.

  5. Curr N, Saunders H, Murugasu A, et al; Multiple periungual pyogenic granulomas following systemic 5-fluorouracil. Australas J Dermatol. 2006 May47(2):130-3.

  6. Paul LJ, Cohen PR; Paclitaxel-associated subungual pyogenic granuloma: report in a patient with breast cancer receiving paclitaxel and review of drug-induced pyogenic granulomas adjacent to and beneath the nail. J Drugs Dermatol. 2012 Feb11(2):262-8.

  7. Durgun M, Selcuk CT, Ozalp B, et al; Multiple disseminated pyogenic granuloma after second degree scald burn: a rare two case. Int J Burns Trauma. 2013 Apr 183(2):125-9. Print 2013.

  8. Kamal R, Dahiya P, Puri A; Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012 Jan16(1):79-82. doi: 10.4103/0973-029X.92978.

  9. Jafarzadeh H, Sanatkhani M, Mohtasham N; Oral pyogenic granuloma: a review. J Oral Sci. 2006 Dec48(4):167-75.

  10. Marghoob A et al; An Atlas of Dermoscopy, Second Edition, 2012.

  11. Arikan DC, Kiran G, Sayar H, et al; Vulvar pyogenic granuloma in a postmenopausal woman: case report and review of the literature. Case Rep Med. 20112011:201901. doi: 10.1155/2011/201901. Epub 2011 Sep 8.

  12. Ravi V, Jacob M, Sivakumar A, et al; Pyogenic granuloma of labial mucosa: A misnomer in an anomolous site. J Pharm Bioallied Sci. 2012 Aug4(Suppl 2):S194-6. doi: 10.4103/0975-7406.100269.

  13. Pyogenic granuloma; Primary Care Dermatology Society, 2012

  14. Zaballos P, Carulla M, Ozdemir F, et al; Dermoscopy of pyogenic granuloma: a morphological study. Br J Dermatol. 2010 Dec163(6):1229-37. doi: 10.1111/j.1365-2133.2010.10040.x.

  15. Lacarrubba F, Caltabiano R, Micali G; Dermoscopic and histological correlation of an atypical case of pyogenic granuloma. Pediatr Dermatol. 2013 Jul30(4):499-501. doi: 10.1111/pde.12123. Epub 2013 Mar 14.

  16. Sacchidanand S, Purohit V; Sclerotherapy for the treatment of pyogenic granuloma. Indian J Dermatol. 2013 Jan58(1):77-8. doi: 10.4103/0019-5154.105317.

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