A 22-year-old woman comes in to the clinic for a new growth that has evolved over the past 3 months on her finger (Figure 167-1). It started at the end of her pregnancy and she is now postpartum. The growth is painless, but bleeds easily. She was diagnosed with a probable pyogenic granuloma (PG) and treatment options were discussed. She opted for shave excision, followed by curettage and electrodesiccation (Figure 167-2). The tissue was sent for pathology and confirmed the diagnosis of PG. On follow-up the site was healing well and the patient was very happy with the result.
Pyogenic granuloma on the finger that started in pregnancy.
Pyogenic granuloma treatment. A. Shave excision to be sent for pathology. B. Curettage of the base. C. Electrodesiccation of the base. D. Immediate final result. Note how the stalk was much narrower than the lesion itself. (Reproduced with permission from Richard P. Usatine, MD.)
Pyogenic granuloma (PG) is a relatively common benign acquired vascular growth of the skin and mucous membranes.
PG is also known as lobular capillary hemangioma (LCH) due to its histologic appearance. PG is a misnomer as it is neither pyogenic nor granulomatous. However, it often has a purulent-appearing exudate that explains how it got its name (Figure 167-3).
Pyogenic granuloma that started with trauma from a three-ring binder. Note how it appears purulent, explaining how it got named "pyogenic" despite the fact that it is not a bacterial infection. (Reproduced with permission from Richard P. Usatine, MD.)
Seen most commonly in children, teens, and young adults. Mean onset in children is age 6.7, but can occur throughout childhood. Generally acquired, but 1% are present at birth.1
Oral lesions are more common in women, particularly in the 2nd and 3rd decades of life, and in pregnancy.1
PGs have also rarely been reported in the GI tract, nose, conjunctiva, and subcutaneous and intravenous locations.
ETIOLOGY AND PATHOPHYSIOLOGY
Etiology is unknown. PGs may be associated with prior trauma (see Figure 167-3), wound, and hormonal changes, but a direct relationship has not been proven.
It is hypothesized that pro-angiogenic growth factors play a role in development of PG. This may account for the reported response of pediatric PGs to beta blockers.2
Histopathology demonstrates proliferation of capillaries and venules with neutrophilic infiltrates, in a lobular pattern.3,4
Prior local trauma (in a minority of patients).1
Pregnancy (Figure 167-4) and oral contraceptives may be risk factors, possibly due to the effect of hormones on angiogenesis.
Medications (including retinoids, protease inhibitors, and antineoplastic agents).3
Bartonella—associated with increased Bartonella seropositivity in one report.1
Manipulation—infrequently, satellite PG lesions can occur.
Pyogenic granuloma on the face of a 25-year-old woman who is 32 weeks pregnant. (Reproduced with permission from Richard P. Usatine, MD.)
Painless red papule or nodule that is friable and bleeds easily even with minor trauma. Several millimeters to several centimeters in size.
Usually singular, but occasionally multiple lesions.
Develops rapidly over several weeks.
May ulcerate (Figure 167-5) or crust over.
Pyogenic granuloma on the scalp of a 31-year-old man with significant ulcerations. It is very friable and bleeds easily. (Reproduced with permission from Richard P. Usatine, MD.)
Most commonly found on the head, neck, trunk, and upper limbs. Hands and fingers are the most frequent sites on the upper limb (Figure 167-6). PGs are also found on the scalp (see Figure 167-5).
In pregnant women, PG found most frequently on the oral mucosa.
Rarely, lesions may be subcutaneous, IV, or visceral.
Large pyogenic granuloma on the finger of a man present for 2 months. Note how the base is narrower than the lesion. This is very typical. (Reproduced with permission from Richard P. Usatine, MD.)
Dermoscopy reveals reddish homogenous areas, white collarettes, "white rail" lines and ulceration, all of which are associated with PGs (Figure 167-7).5
Multiple patterns or combinations of the above can be seen in PGs.5
Reddish homogeneous area, white collarettes, and white rail lines together had a specificity for PG of 100%.5
Dermoscopy of a pyogenic granuloma showing a white collarette pattern around the edge with white rail lines inside the lesion. (Reproduced with permission from Richard P. Usatine, MD.)
Capillaries in edematous stroma with associated neutrophilic infiltrate. Over time, develops an increasingly lobular pattern. Often the lesion has a surrounding epidermal collarette. Develops increasing fibrosis before regressing.1,3,4,6
It is crucial to send the specimen to pathology to rule out amelanotic melanoma (Figure 167-8).
Amelanotic melanoma on the nose that could be confused with a pyogenic granuloma. Always send what you suspect to be a PG to the pathologist. (Reproduced with permission from Richard P. Usatine, MD.)
Malignancies that can be mistaken for PG include basal cell cancer, squamous cell cancer, keratoacanthoma, amelanotic melanoma (see Figure 167-8), cutaneous metastatic lesions, and Kaposi sarcoma. Therefore, every PG that is excised should be sent to pathology.
Benign tumors that can resemble PG include hemangiomas (Figure 167-9), angiokeratomas, and fibrous papules.
Bacillary angiomatosis may be confused with PG, and its histopathology has similar features (see Figure 226-10). It is a rare infection seen more commonly in patients in patients with AIDS or advanced immunosuppression.4
Hemangioma on the lip of a 67-year-old man. By appearance alone this is hard to differentiate from a pyogenic granuloma (lobular capillary hemangioma). This did not bleed extensively at time of excision, and the pathology result confirmed that this was a hemangioma. (Reproduced with permission from Richard P. Usatine, MD.)
A. Recurrent pyogenic granuloma on the lip of a 33-year-old woman. The original lesion was treated with shave excision, curettage, and electrodesiccation 1 month ago. B. Swollen lip and sutured incision after the excision of a pyogenic granuloma. A chalazion clamp was used to assist with the surgery and help control the bleeding. The lip is swollen from the lidocaine and epinephrine needed to perform the surgery. C. The lip has healed beautifully 1 month after surgery, and any faint signs of surgery will fade over time. (Reproduced with permission from Richard P. Usatine, MD.)
PGs eventually resolve slowly over time. However, patients often opt for treatment for cosmetic reasons or due to bleeding. Treatment options include both pharmacologic and surgical approaches. If clinicians have any diagnostic uncertainty, the lesion should be removed and sent to pathology.
Treatment choice is usually driven by the patient's age, location of the lesion, cosmetic concerns, and whether there is any diagnostic uncertainty. Younger pediatric patients with typical PG lesions may be treated with topical agents or cryotherapy.
A number of small series of patients have been treated successfully with topical imiquimod 5% cream. The frequency of application has varied from three times a week to twice daily for periods ranging from 2 to 8 weeks.7 SORⒸ
Topical timolol 0.5% gel is frequently used for treatment of superficial infantile hemangiomas. Recently, case reports indicate that PG may be treated successfully with topical timolol two to three times a day for weeks or months.2 SORⒸ
Surgical excision has the lowest recurrence rate (3.7%), but has a higher incidence of scarring (55%).8 SORⒸ It is not uncommon for PGs of the lip to recur unless treated with surgical excision (Figure 167-10).
Shave excision followed by curetting and electrodesiccation of the base has a recurrence rate of 10%, with scarring in approximately 30%.8 SOR PGs bleed extensively when manipulated or cut. It is important to use lidocaine with epinephrine, wait 10 minutes for the epinephrine to work, and have an electrosurgery device to control bleeding. Cut the PG off with a blade and send to pathology. Curetting the base will also help stop the bleeding and prevent recurrence. The base is curetted and electrodesiccated until the bleeding stops. SORⒸ
Laser surgery often requires more than one treatment session, and scarring and recurrence rates are variable.8 SORⒸ
Cryotherapy has low recurrence rates but often requires more than one treatment, and it is often associated with scarring (42%) (Figure 167-11).8,9 SORⒸ
Cryotherapy of a pyogenic granuloma using a Cryo Tweezer. The young girl was afraid of needles so would not permit excision but did tolerate the cryotherapy well. (Reproduced with permission from Richard P. Usatine, MD.)
Inform patients that these lesions are benign and will often resolve spontaneously over months to years. However, there are several effective treatment options available if desired for cosmetic reasons or to prevent bleeding.
If the lesion recurs, early follow-up is appropriate, as small lesions are generally easier to treat than large ones.
CK. Pyogenic Granuloma. Cutis
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