> Table of Contents > Granuloma, Pyogenic
Granuloma, Pyogenic
Eddie Needham, MD, FAAFP
image 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.
image DIAGNOSIS
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
  • P.427

  • No true granuloma formation
  • Abundant mitotic activity
  • Resembles granulation tissue in an edematous matrix, showing immature capillaries with interspersed tissue
image 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.
image 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.
REFERENCES
1. Lin RL, Janniger CK. Pyogenic granuloma. Cutis. 2004;74(4):229-233.
2. 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.
3. Kroumpouzos G, Cohen LM. Dermatoses of pregnancy. J Am Acad Dermatol. 2001;45(1):1-19.
4. Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. 2004;21(1):10-13.
5. Gilmore A, Kelsberg G, Safranek S. Clinical inquiries. What's the best treatment for pyogenic granuloma? J Fam Pract. 2010;59(1):40-42.
6. 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
&NA;
  • 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
&NA;
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
Clinical Pearls
&NA;
  • 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.