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AUTHOR AND EDITOR INFORMATION

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Author: Mark A Crowe, MD, Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine

Mark A Crowe is a member of the following medical societies: American Academy of Dermatology and North American Clinical Dermatologic Society

Coauthor(s): Brett Steinberg, DO, Staff Physician, Department of Internal Medicine, Walter Reed Army Medical Center

Editors: Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center

Author and Editor Disclosure

Synonyms and related keywords: pyogenic granuloma, PG, granuloma gravidarum, granuloma telangiectaticum, lobular capillary hemangioma, pregnancy tumor, gingival lesion, exophytic circumscribed lesion, polymorphonuclear leukocytes, satellitosis, intravenous pyogenic granuloma, nevi, warts, port-wine stain, amelanotic melanoma, human papillomavirus, bacillary angiomatosis, polymorphonuclear leukocytes

INTRODUCTION

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Background

Pyogenic granulomas (PGs) are benign vascular lesions that occur most commonly on the acral skin of children. The term PG is a misnomer. Originally, these lesions were thought to be caused by bacterial infection; however, the etiology has not been determined. The histopathologic appearance is fairly characteristic; the lesion is, in fact, a lobular capillary hemangioma.

Recognition of PG as a clinically polypoid or exophytic circumscribed lesion is of importance to the clinician and pathologist because this feature distinguishes PG from most malignant vascular tumors. Although PGs may be multiple (especially on the skin) and necrosis is common, invasion of adjacent structures is not observed. The lesions grow rapidly and are extremely vascular, frequently bleeding either spontaneously or after minor trauma. They are usually easily treated with surgical removal but may recur.

Uncommon variants include PG with satellitosis and intravenous PG. Satellite lesions of smaller PGs may develop at the same time as the primary lesion or may occur after attempted treatment of the primary lesion.

Pathophysiology

Although most patients (74.2%) do not have a history of trauma or predisposing dermatologic conditions, in many cases, a history of recent trauma at the site is present. A nitric oxide synthase–dependent mechanism is thought to contribute to angiogenesis and the rapid growth of PGs. They are benign vascular proliferations, but the specific pathophysiology of these lesions is unknown.

Frequency

United States

PGs account for 0.5% of skin lesions in infants and children and are also found in the oral mucosa in 2% of pregnant women.

Mortality/Morbidity

Most PGs are asymptomatic except for mild tenderness and a tendency to bleed with little or no trauma. They are benign and easily treated.

Race

No substantial difference in incidence is found between races.

Sex

One study of 178 patients younger than 17 years reported the male-to-female ratio as 3:2.1 In adults, PGs are more common in females because of pregnancy-related lesions.

Age

PGs are most common in the first 5 years of life.


CLINICAL

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History

Patients usually seek care because the lesion has grown rapidly and bleeds easily. Patients or parents may be concerned because the lesion bleeds with little or no trauma; they are frequently concerned that the rapid growth and bleeding may indicate a malignancy.

Important questions include the following:

  • Does the history include trauma at the site prior to development of the lesion? Pyogenic granulomas (PGs) may occur following minor physical trauma or burns.
  • How long has the lesion been present? Most PGs develop rapidly. The mean duration at the time of diagnosis is approximately 3 months. If the lesion has been present longer than 6 months, the possibility of cutaneous malignancy increases.
  • Does the lesion bleed easily? Almost all PGs bleed easily. If the lesion does not bleed with light rubbing, a diagnosis of PG is unlikely.
  • What therapy has been used recently? Nevi, warts, or other lesions may have been treated with caustic agents or cryotherapy prior to referral. Such therapy may markedly change the appearance of the original lesion, causing it to mimic a PG.
  • Is the patient pregnant? Oral PGs can develop during or just after the first trimester of pregnancy. Examine and properly identify these lesions of pregnancy to avoid misdiagnosis and overtreatment. These lesions are not generally harmful in pregnancy; however, induction of labor due to uncontrollable bleeding from a gingival lesion has been reported.2
  • Has the lesion recurred after surgical treatment? If so, was it excised and the skin closed primarily or was it treated with shave removal and electrodesiccation of the base? PGs may recur. This is more likely when they are incompletely removed, but recurrence is also possible after apparently complete removal. PGs are more likely to recur after shave removal and electrodesiccation of the base than after surgical excision.
  • Has the patient taken oral retinoid therapy (isotretinoin [Accutane]) recently? Facial PG-like lesions during isotretinoin therapy have been reported.

Physical

  • PGs appear as smooth firm nodules, with or without crusts, and they may have a bright or dusky red color. They are usually solitary, well circumscribed, dome shaped, 1-10 mm in diameter, and sessile or pedunculated.
  • In children, PGs are most commonly located on the head and neck (62.4%) and, in order of decreasing frequency, on the trunk (19.7%), upper extremity (12.9%), and lower extremity (5.0%). Most (88.2%) occur on the skin, and the rest involve mucous membranes of the oral cavity and conjunctivae.
  • In pregnant women, PGs are most often found on the gingival mucosa but they have been known to appear in nonoral areas such as the fingers and inguinal crease.
  • PGs may occur within a port-wine stain; the presence of a vascular birthmark in the region of the PG may be significant.
  • Amelanotic melanoma may closely mimic a PG in appearance. Closely examine the skin immediately adjacent to the lesion for any pigmentary irregularity.

Causes

  • Originally, PGs were thought to be caused by bacterial infection; the etiology has yet to be determined. Postulated etiologies include viral, hormonal, and, more recently, angiogenic factors.
  • PGs have been evaluated for the presence of human papillomavirus (HPV) because warts occur in similar age groups and sites. Lesions were tested for HPV 6, 11, 16, 31, 33, 35, 42, and 58. No viruses were present.
  • Recurrent PG with satellitosis is an uncommon variant. In one patient with recurrent PG with satellitosis, Warthin-Starry staining of the lesions revealed clumps of dark bacilli as found in patients with bacillary angiomatosis.3 An indirect immunofluorescence assay showed elevated immunoglobulin G antibodies against Bartonella (Rochalimaea) henselae. The patient did not present an obvious risk for human immunodeficiency virus (HIV) infection or immunosuppression; no antibodies against HIV-1 and HIV-2 were found. Recurrent PG with satellitosis may be a localized variant of bacillary angiomatosis.


DIFFERENTIALS

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Other Problems to be Considered

Amelanotic malignant melanoma
Angiolymphoid hyperplasia with eosinophilia
Bacillary angiomatosis
Basal cell carcinoma
Benign lymphangioendothelioma
Eruptive epithelioid hemangioendothelioma with spindle cells
Facial pyogenic granuloma (PG)-like lesions associated with isotretinoin therapy
Glomeruloid hemangioma
Glomus tumor
Intravascular papillary endothelial hyperplasia
Kaposi sarcoma
Kaposiform hemangioendothelioma
Metastatic carcinoma
Microvenular hemangioma
Spindle-cell hemangioendothelioma
Squamous cell carcinoma
Targetoid hemosiderotic hemangioma
Tufted hemangioma


WORKUP

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Procedures

  • Obtain a biopsy of any lesion suspected of being a pyogenic granuloma to confirm the diagnosis.

Histologic Findings

Proliferation of capillaries is present, with prominent endothelial cells embedded in edematous gelatinous stroma in a characteristic lobular configuration. The epidermis is commonly eroded. A dense infiltrate and granulation tissue with polymorphonuclear leukocytes may be present. Hyperproliferation of the epidermis is usually present at the margins of the vascular growth, which results in a collarette of epidermis.


TREATMENT

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Surgical Care

  • Treatment most commonly consists of shave removal and electrocautery or surgical excision with primary closure. Removal of the lesion is indicated for bleeding due to trauma, discomfort, cosmetic distress, and diagnostic biopsy. The lesion may be completely removed during biopsy.
  • For solitary lesions, a shave excision and electrocautery under local anesthesia is the treatment of choice. To provide an adequate cure rate, all vascular granulation tissue must be removed or cauterized.
  • For large or recurrent lesions, surgical excision with primary closure may be more effective. One study reported a 43.5% recurrence rate in 23 lesions treated by shave (intradermal) excision and cautery or cautery alone.1 Lesions treated by full-thickness skin excision and linear closure did not recur.
  • Therapy with the pulsed-dye laser at vascular-specific 585 nm is very selective, usually requires no anesthesia, and produces excellent cosmetic results. The pulsed-dye laser works quite well for intraoral pyogenic granulomas (PGs), as observed in pregnant women. Although treatment is feasible, treatment during pregnancy is not necessary because the lesions may recur during the pregnancy and generally resolve with delivery.
  • Cryotherapy or silver nitrate therapy may be effective for very small lesions; however, treatment failure rates are high.
  • In pediatric cases, a eutectic mixture of local anesthetics (EMLA) applied to the lesion and surrounding skin under an occlusive dressing for 1-2 hours prior to additional intralesional anesthesia may be of significant value.

Consultations

Consider referral to a dermatologist if the diagnosis is in doubt or if the availability of adequate therapy is questionable.


MEDICATION

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Despite the necrosis, foul odor, and purulent drainage noted occasionally with pyogenic granulomas (PGs), antibiotic therapy is rarely required.


FOLLOW-UP

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Further Outpatient Care

  • Following removal of the pyogenic granuloma (PG), routine wound care is the only treatment required.
  • Follow-up visits are required only if the lesion recurs. If the lesion recurs and histopathology confirms the diagnosis, the recurrent lesion may be treated with any of the modalities previously discussed, including simply repeating the initial therapy.

Complications

  • Significant secondary infection (extremely uncommon)
  • Recurrence at the original site
  • Recurrence as multiple satellite lesions in the area immediately surrounding the original lesion
  • Superficial scar formation
  • Oral PG
    • An oral PG can develop during or just after the first trimester of pregnancy.
    • Usually, an oral PG is an early slow-growing mass that, upon excision, does not leave a large defect in the periodontium that requires surgical repair.
    • Rarely, a rapidly growing large tumor may produce significant hemorrhage.

Prognosis

  • Prognosis is excellent after simple removal and wound care.


MISCELLANEOUS

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Medical/Legal Pitfalls

  • Failure to diagnose and adequately treat an amelanotic melanoma is the most significant concern. Although amelanotic melanoma is extremely rare in children, histologic examination should always be performed to confirm the diagnosis.


MULTIMEDIA

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Media file 1:  Pyogenic granulomas are usually solitary lesions. The fingers and hands are common locations for these to develop. A history of minor trauma at the site shortly before development of the lesion is frequent.
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Media type:  Photo

Media file 2:  Pyogenic granulomas usually bleed with little or no trauma. This patient shows a positive bandage sign. Because the lesions bleed so easily, patients frequently present with a bandage covering the site.
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Media type:  Photo

Media file 3:  Pyogenic granulomas usually have a distinct margin that consists of a rim of keratin (dry skin). Notice the moist area of skin produced by the bandage, which was removed shortly before the photograph was taken.
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Media type:  Photo

Media file 4:  Pyogenic granulomas may be pedunculated and quite large. An area of necrosis is also common.
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Media type:  Photo

Media file 5:  Pyogenic granulomas may occur at various sites. More than 60% of all lesions develop on the head and neck.
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Media type:  Photo

Media file 6:  Unlike pyogenic granulomas, cherry angiomas such as these are slow to develop, do not bleed easily, are frequently multiple, are more commonly found on the trunk, and seldom have a history of prior trauma.
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Media type:  Photo

Media file 7:  Several malignant tumors may mimic pyogenic granulomas. This lesion is a squamous cell carcinoma. Amelanotic melanomas (little or no overt pigment) are also included in the differential diagnosis. These tumors are usually slower growing than pyogenic granulomas and are uncommon in children. Tissue removed as part of the treatment process should be sent for histopathologic examination to confirm the diagnosis.
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Media type:  Photo

Media file 8:  Small pyogenic granuloma.
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Media type:  Photo


REFERENCES

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Pyogenic Granuloma excerpt

Article Last Updated: Dec 4, 2007