BASICS
DESCRIPTION
- Pyogenic granulomas (PG) are benign, acquired, and solitary vascular proliferations that occur most often on the head and neck, the lips and oral cavity, the trunk, and the extremities (1).
- They are friable and tend to bleed easily due to the vascular nature of the lesion.
- Smooth, red to purple, sessile or pedunculated, grow rapidly over several weeks
- Synonym(s): Given that PG are neither pyogenic nor granulomatous, another term is lobular capillary hemangioma.
EPIDEMIOLOGY
The peak incidence of PG are the 2nd and 3rd decades of life (2).
Incidence
- In children, PG accounts for <1% of all skin lesions.
- 42% of all cases occur by age 5 years (2).
- 2% of pregnant women in the United States develop a PG by 5 months' pregnancy (3).
Prevalence
Relatively common condition
ETIOLOGY AND PATHOPHYSIOLOGY
- Thought to be an aberrant healing response to minor trauma in many cases
- May be related to hormonal changes in pregnancy
- Not caused by bacterial infection but associated with capillary proliferation
- Not considered as a hemangioma or neoplasm
- Associated with acute and chronic trauma, peripheral nerve injury, inflammatory systemic diseases, infection, drugs (systemic steroids, protease inhibitors, retinoids, epidermal growth factor receptor inhibitors)
RISK FACTORS
- Pregnancy
- Trauma
- Intraoral trauma or surgery
- Inflammatory systemic diseases
GENERAL PREVENTION
Good oral hygiene may be helpful.
DIAGNOSIS
HISTORY
- Solitary lesion that develops rapidly from days to weeks after minor trauma
- Tends to bleed easily
- Grows early in pregnancy and partially regresses postpartum
PHYSICAL EXAM
- Most commonly located at the head, neck, and upper extremities, especially in children
- Among oral lesions, gingiva is the most common location.
- Usually a bright red, friable papule; can also be purple, yellow, or brown
- Moist and sometimes scaly-appearing surface
- Usually <1 cm but ranges from a few millimeters to 2 to 3 cm in diameter
- Giant lesions may occur on areas such as the foot (rare).
- Soft; pedunculated or sessile
- Solitary red papule, grows rapidly, forming a stalk, may bleed, and ulcerate.
- On diascopy, red structureless areas surrounded by a white collarette intersected by white lines
- Erythematous, soft compressible papule with serosanguineous crusting and sharp demarcation
DIFFERENTIAL DIAGNOSIS
- Benign lesions
- Cherry/infantile hemangioma (4)
- Fibrous papule (1,4)
- Bacillary angiomatosis, from by Bartonella (1)
- Malignant lesions
- Basal cell carcinoma (1)
- Squamous cell carcinoma (1)
- Amelanotic melanoma (1)
- Kaposi sarcoma (1)
- Cutaneous metastases (1)
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
No labs are necessary for the diagnosis.
Diagnostic Procedures/Other
- Excisional/shave biopsy
- Send for pathology.
Test Interpretation
Microscopic examination reveals
- Small, endothelial-lined vascular spaces
- Loose/dense connective tissue stroma
- Acute and chronic inflammatory cells
- No true granuloma formation
- Abundant mitotic activity
- Resembles granulation tissue in an edematous matrix, showing immature capillaries with interspersed tissue
TREATMENT
When feasible, surgical excision is best to yield material for histopathologic analysis (1,5).
MEDICATION
- Cryotherapy with liquid nitrogen (recur 2%) (6)[B]
- Laser (recur 5%) (6)[B]
- Topical imiquimod (recur 0%) (6)[B]
- Silver nitrate (recur 15%) (6)[A]
- Topical 1.5% phenol solution may be used for periungual lesion (6)[B].
- Perform excision for bx if recurrent.
SURGERY/OTHER PROCEDURES
- Excisional biopsy should be tried in all situations, if possible, to ensure a proper diagnosis (i.e., not missing malignancies such as amelanotic melanoma or basal cell carcinoma) (recur 2-3%) (6)[B]. For smaller lesions in noncosmetically sensitive areas, surgical excision with simple closure gives the best result with least recurrence (6)[B].
- Liquid nitrogen may be nonsurgical option with the lowest recurrence rate (recur 2%) (6)[B].
- Shave excision with cautery may be optimal treatment for a lesion on fingertips (recur 7-9%) (6)[B].
- Electrosurgery: electrodesiccation and curettage (recur 7-9%) (6)[B]
- Excision must be adequate to avoid recurrence. Even a small fragment of tissue left behind may lead to recurrence.
ONGOING CARE
PATIENT EDUCATION
Patient should avoid trauma to area following excision.
PROGNOSIS
- Some lesions spontaneously resolve on their own (usually within 6 months).
- Complete resolution is expected with adequate excision.
COMPLICATIONS
Recurrence: After removal or destruction of solitary lesion, multiple satellite lesions can form around original treatment site.
REFERENCES
11 Lin RL, Janniger CK. Pyogenic granuloma. Cutis. 2004;74(4):229-233.22 Harris MN, Desai R, Chuang TY, et al. Lobular capillary hemangiomas: an epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol. 2000;42(6):1012-1016.33 Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am Acad Dermatol. 2001;45(1):1-19.44 Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. 2004;21(1):10-13.55 Gilmore A, Kelsberg G, Safranek S. Clinical inquiries. What's the best treatment for pyogenic granuloma? J Fam Pract. 2010;59(1):40-42.66 Lee J, Sinno H, Tahiri Y, et al. Treatment options for cutaneous pyogenic granulomas: a review. J Plast Reconstr Aesthet Surg. 2011;64(9):1216-1220.
ADDITIONAL READING
- Greene AK. Management of hemangiomas and other vascular tumors. Clin Plast Surg. 2011;38(1):45-63.
- Losa Iglesias ME, Becerro de Bengoa Vallejo R. Topical phenol as a conservative treatment for periungual pyogenic granuloma. Dermatol Surg. 2010;36(5):675-678.
- Piraccini BM, Bellavista S, Misciali C, et al. Periungual and subungual pyogenic granuloma. Br J Dermatol. 2010;163(5):941-953.
- Zalaudek I, Kreusch J, Giacomel J, et al. How to diagnose nonpigmented skin tumors: a review of vascular structures seen with dermoscopy: part II. Nonmelanocytic skin tumors. J Am Acad Dermatol. 2010;63(3):377-386.
CODES
ICD10
- L98.0 Pyogenic granuloma
- K06.8 Oth disrd of gingiva and edentulous alveolar ridge
- K13.4 Granuloma and granuloma-like lesions of oral mucosa
- K04.5 Chronic apical periodontitis
ICD9
- 686.1 Pyogenic granuloma of skin and subcutaneous tissue
- 522.6 Chronic apical periodontitis
- 528.9 Other and unspecified diseases of the oral soft tissues
SNOMED
- 200722003 Pyogenic granuloma (disorder)
- 235002009 Gingival pyogenic granuloma (disorder)
- 447222001 Granuloma gravidarum (disorder)
CLINICAL PEARLS
- Benign, acquired, usually rapidly growing, solitary vascular proliferation that involves exposed areas, such as distal extremities and face, as well as in the oral cavity
- Excision must be adequate to avoid recurrence.
- Excisional biopsy recommended to ensure proper diagnosis (and to not miss a malignant lesion)
- Excision with primary closure or excision with cautery should be the first choice for treatment in most lesions.