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Chapter 111: Pyogenic Granuloma (Granuloma Teleangiectaticum, Lobular Capillary Hemangioma)

Uwe Wollina

PYOGENIC GRANULOMA (GRANULOMA TELEANGIECTATICUM, LOBULAR CAPILLARY HEMANGIOMA)

Therapeutic Approach

Pyogenic granuloma (PG) is a benign vascular proliferation of skin and mucous membranes. The rapidly growing exophytic tumors are often pendulating and have a tendency to bleed. Secondary infections are possible. Causative factors are trauma and some medications, such as targeted tumor therapies. The most common sites of PG are fingers, toes, lips, and gingiva. The authors prefer topical corticosteroids for smaller lesions if a surgical approach is not wanted. All drugs listed are used off-label. For most cases we would prefer, however, diode laser therapy due to its rapid action and high efficacy. See Table 111-1.

Table 111-1Pyogenic Granuloma Treatment Table
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Table 111-1 Pyogenic Granuloma Treatment Table
MEDICATION NAME MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Topical corticosteroids Downregulation of vascular endothelial growth factor A (VEGF-A), reduction nuclear factor κ-light-chain enhancer of activated B cells (NF-κB) activity

0.5% clobetasol propionate ointment

Topical corticosteroids can be used in children, when surgery is not wanted

 Skin atrophy after prolonged usage None IV1-3
Topical imiquimod Anti-angiogenic

5% imiquimod cream once a day 2-17 wk

Less appropriate for children

 Skin irritation None III1,2,4-6
Topical timolol maleate Beta-adrenergic antagonist, downregulation of proangiogenic cytokines

0.5% ointment for at least 3 wk OR 0.1% solution under occlusive dressing for 2 wk; eye-drop of ocular PG; BID

Has been used in children occasionally

 Bradycardia, hypotension, hypoglycemia, and bronchoconstriction due to systemic absorption Blood pressure, heart rate III1,2,7-11
Topical propranolol Beta-adrenergic antagonist, downregulation of proangiogenic cytokines

1% cream; once a day; up to 45 d

Has been used in children occasionally

 Bradycardia, hypotension, hypoglycemia, and bronchoconstriction due to systemic absorption Blood pressure, heart rate III1,2,7,8,12-14
Topical ingenol mebutate Disruption of plasma membrane and mitochondria, which leads to necrosis of locally affected cells, downregulation of vascular endothelial growth factor (VEGF)

0.015% cream; once daily for 3 d per week

For adults

 Erythema, crusting, and flaking or scaling of skin None IV15
Topical phenol Sclerosant, induces apoptosis

98% or 8% solution for 1 min weekly

For adults

 Initially painless white patches and later turn erythematous and finally brown; can cause acute toxicity None IV1,2,16,17
Topical alitretinoin

Anti-inflammatory and immunomodulatory effects

Antiproliferative and apoptotic effects also on endothelial cells

0.1% gel; BID

For adults (see contraindications)

 Erythema and edema, seldom ulcerations at application sites; contraindicated during pregnancy and lactation, in case of moderate to severe hepatic or renal insufficiency, hypervitaminosis A, children Blood count, liver enzymes, lipid profile, pregnancy test—before treatment and every 4 wk IV18
Mitomycin C eye drops Alkylating agent

0.02% 4 times a day for 2 wk

For adults and ocular lesions only

 Hyperemia, eye pain ...

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