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AUTHOR AND EDITOR INFORMATION

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Author: Joseph C Pierson, MD, Consulting Staff, Department of Dermatology, Keller Army Community Hospital

Joseph C Pierson is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Coauthor(s): Diane M Pierson, DO, Fellow, Department of Hematopathology, MD Anderson Cancer Center, University of Texas at Houston

Editors: Donald Belsito, MD, Clinical Professor, Department of Internal Medicine, Division of Dermatology, University of Missouri at Kansas City; Private Practice, American Dermatology Associates, LLC; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System

Author and Editor Disclosure

Synonyms and related keywords: pyogenic granuloma, lobular capillary hemangioma, granuloma pyogenicum, granuloma telangiectaticum,  granuloma pediculatum, pregnancy tumor, granuloma of pregnancy, granuloma gravidarum, epulis gravidarum, pregnancy epuloids

INTRODUCTION

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Background

Pyogenic granuloma is a relatively common benign vascular lesion of the skin and mucosa whose exact cause is unknown. This misnamed entity is neither infectious nor granulomatous. The lesion usually occurs in children and young adults as a solitary glistening red papule or nodule that is prone to bleeding and ulceration. It typically evolves rapidly over a period of a few weeks, most often on the head, neck, extremities, and upper trunk.

Pyogenic granuloma often arises in pregnancy (or rarely with oral contraceptive usage), particularly on the gingiva or elsewhere in the oral mucosa, and then is termed the "pregnancy tumor." Other pyogenic granuloma variants that have been well documented include the disseminated, subcutaneous, intravenous, and systemic medication (retinoid, protease inhibitor, and chemotherapy)–induced subtypes.

Removal of the lesion is indicated to alleviate any bleeding, discomfort, cosmetic distress, and diagnostic uncertainty. A number of malignant tumors may clinically mimic pyogenic granuloma, making histopathologic confirmation important if the presentation is atypical. Aside from cutaneous and oral lesions, pyogenic granuloma has been reported throughout the gastrointestinal tract, the nasal mucosa, the larynx, and the conjunctiva and cornea. This article discusses only cutaneous and oral involvement.

Pathophysiology

The precise mechanism for the development of pyogenic granuloma is unknown. Trauma, hormonal influences, viral oncogenes, underlying microscopic arteriovenous malformations, the production of angiogenic growth factors, and cytogenetic abnormalities have all been postulated to play a role.

Frequency

United States

Pyogenic granuloma is relatively common. It represents 0.5% of all skin nodules in children. The pregnancy tumor variant of pyogenic granuloma occurs in up to 5% of pregnancies.

International

International frequency is likely similar to that of the United States.

Mortality/Morbidity

Pyogenic granuloma is a benign lesion; however, discomfort and bleeding occasionally may be significant. The latter may rarely be severe enough to cause anemia.1 Lesions that recur despite repeated excisions can be particularly problematic.

Race

Frequency appears to be similar in all races.

Sex

Females are affected more commonly due to the pregnancy tumor phenomenon.

Age

Pyogenic granuloma is rare in children younger than 6 months. The mean age of presentation is 6.7 years. Otherwise, aside from those lesions occurring in pregnancy, the frequency declines linearly with age.


CLINICAL

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History

The common solitary pyogenic granuloma grows rapidly to its maximum size over a period of a few weeks.

Patients may report a glistening red lesion that bleeds spontaneously or after trauma. A history of trauma preceding the onset of the lesion may be elicited. Untreated lesions eventually atrophy, become fibromatous, and slowly regress.

The head, neck, digits, and upper trunk are affected most commonly.

A few reports of lesions developing in a preexisting nevus flammeus or spider angioma exist (see Capillary Malformation for more information on this topic).

Systemic retinoids may occasionally trigger pyogenic granuloma–like lesions. These occurred more frequently just after the approval of isotretinoin. In current practice, a lower initial dose is used and this phenomenon is unusual. Several reports have described pyogenic granulomas occurring with the use of topical retinoids.2

The use of indinavir, a protease inhibitor, has been associated with the development of pyogenic granulomas, predominantly of the great toes.3 In addition, pyogenic granuloma–like lesions developing during systemic 5-fluorouracil,4 capecitabine (a fluoropyrimidine),5 mitoxantrone,6 and epidermal growth factor receptor inhibitor chemotherapy7 have all been documented.

The pregnancy tumor variant most often occurs in the second or third trimester.

Rare multiple lesions may be grouped or eruptive and disseminated in nature.

Adolescents and young adults are more prone to develop multiple recurrent lesions after prior attempts at removal, especially on the trunk.

Physical

The typical solitary lesion is a bright red, friable polypoid papule or nodule ranging from a few millimeters to several centimeters (average size is 6.5 mm). Bleeding, erosion, ulceration, and crusting frequently are noted. Regressing lesions appear as a soft fibroma. The head and neck (specifically the gingiva, lips, nasal mucosa, and face), distal extremities (especially the fingers) are the sites of predilection, but lesions occur anywhere on the integument.

The pregnancy tumor variant of pyogenic granuloma most frequently is found along the maxillary intraoral mucosal surface, but any intraoral, perioral, and nonoral tissue may be involved.

Pyogenic granuloma with satellitosis, a subcutaneous subtype, and a disseminated variant have been described. The majority of satellites occur on the trunk, often around the scapula.

The subcutaneous subtype is commonly found on the upper extremity. A rare intravenous variant may present as a vascular polyp on the neck or upper extremities.

Causes

The cause of the typical pyogenic granuloma is not known. Trauma, hormonal influences, Bartonella species seropositivity, viral oncogenes, underlying microscopic arteriovenous malformations, production of angiogenic factors, and cytogenetic clonal deletion abnormalities8 have all been implicated. While trauma was long considered a primary cause, one large study found only 7% of patients had a history of preceding trauma.9 One study found no association between pyogenic granuloma and infection with Bartonella species.10 Development of the lesion in the setting of systemic and topical retinoid, indinavir protease inhibitor, 5-fluorouracil, capecitabine (a fluoropyrimidine), mitoxantrone, and epidermal growth factor receptor inhibitor therapies has been documented (see History), but this phenomenon is not completely understood.


DIFFERENTIALS

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Angiolymphoid Hyperplasia with Eosinophilia
Atypical Fibroxanthoma
Bacillary Angiomatosis
Basal Cell Carcinoma
Cherry Hemangioma
Glomus Tumor
Infantile Hemangioma
Kaposi Sarcoma
Malignant Melanoma
Metastatic Carcinoma of the Skin
Spitz Nevus
Squamous Cell Carcinoma

Other Problems to be Considered

Angioendothelioma
Angiosarcoma
Granulation tissue
Hemangioendothelioma
Intravascular angiomatosis (Masson lesion)
Tufted hemangioma


WORKUP

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Procedures

  • Dermoscopy may be helpful in the recognition of pyogenic granulomas.11 A reddish homogeneous area surrounded by a white collarette is found in the majority of cases.
  • A specimen for histologic examination may be obtained by shave, punch, scalpel, or laser excision.

Histologic Findings

The histopathologic findings in all variants of pyogenic granuloma are similar. Early lesions resemble granulation tissue (numerous capillaries and venules with plump endothelial cells arrayed radially toward the skin surface amidst an edematous stroma containing a mixed inflammatory infiltrate). Often, overlying erosive or ulcerative changes are noted. The matured polypoid lesion exhibits a fibromyxoid stroma separating the lesion into lobules. Reepithelialization of the surface and a peripheral hyperplastic adnexal epithelioid collarette may be noted, and less inflammatory infiltrate is present. A regressing pyogenic granuloma displays extensive fibrosis. The intravenous variant has less lobulation and is connected to the wall of a vein by a stalk. Rarely, extramedullary hematopoiesis may be seen histologically within pyogenic granulomas.12


TREATMENT

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Medical Care

If a clear provoking traumatic factor exists, remove it. Cases attributed to use of medications may regress upon withdrawal of the causative agent.

Topical imiquimod cream13, 14 and alitretinoin gel15 have both been successfully used to treat pyogenic granulomas. A report from Turkey described a patient with multiple pyogenic granulomas who showed clear improvement with oral erythromycin treatment.16

Pyogenic granulomas with satellitosis that recurred after surgical excision have responded to intralesional17 and systemic18 steroids.

Surgical Care

Shave, punch, scalpel, or laser excision may be curative if the lesion is completely removed. If a shave biopsy is performed, curettage with electrodesiccation to the base decreases the likelihood of recurrence. Sclerotherapy, chemical cauterization with silver nitrate, ligation of the base,19 and cryotherapy20 have all been reported effective. Many lesions occurring in pregnancy resolve with parturition; because recurrences are higher during pregnancy, many experts recommend postponing removal until after delivery.

The Medscape Dermatologic Surgery Resource Center may be of interest.


FOLLOW-UP

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Further Outpatient Care

The patient should seek follow-up care as early as possible if any evidence of recurrence of the lesion is present.

Prognosis

Recurrences can occur regardless of the therapeutic modality employed and can be as high as 40-50%. Full thickness skin excision appears to yield the lowest chance of recurrence.

Patient Education

If a clear provoking traumatic factor is causing the lesion, it should be avoided. Instruct patients to avoid oral contraceptives and retinoids if their case can be attributed to such agents.


MISCELLANEOUS

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Medical/Legal Pitfalls

Submit all removed specimens for histologic confirmation of the diagnosis.


MULTIMEDIA

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Media file 1:  Pyogenic granuloma on the neck of the young girl. Courtesy of Jeffrey P. Callen, MD.
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Media type:  Photo

Media file 2:  Multiple recurrent pyogenic granulomas on the neck of the same young girl seen in Image 1. Courtesy of Jeffrey P. Callen, MD.
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Media type:  Photo

Media file 3:  Pyogenic granuloma on the hand. Courtesy of Jeffrey P. Callen, MD.
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Media type:  Photo


REFERENCES

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Pyogenic Granuloma (Lobular Capillary Hemangioma) excerpt

Article Last Updated: Jul 21, 2008