Pyogenic granuloma

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Pyogenic granuloma

Danielle M. DeHoratius

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Pyogenic granuloma, also known as a lobular capillary hemangioma, is a common benign vascular growth. It can rapidly appear and is a solitary, erythematous papule. Pyogenic granulomas are often friable and can frequently ulcerate. They most commonly occur in children and young adults. The etiology is unclear, although reactive neovascularization is suspected because of their occurrence at sites of previous trauma. There is no gender or racial predominance. The most common locations are the head and neck region (including the oral mucosa, especially in pregnant women – granuloma gravidarum) and digits. Occasionally, pyogenic granulomas have been found in subcutaneous or intravascular locations. The term pyogenic granuloma, however, is a misnomer, as there is not an infectious or a granulomatous component to these lesions. Over time they can resolve on their own. Dermoscopy of these lesions can be useful but should not substitute histology. The most sensitive and specific pattern is a reddish homogeneous area, white collarette, and white rail lines.

Management strategy

Pyogenic granulomas are most commonly managed by destruction. This can be completed through shave excision with electrocautery to the base, curettage with electrodesiccation, or cryotherapy. Histologic confirmation is beneficial as other disorders may clinically mimic pyogenic granulomas, examples being amelanotic melanoma, Kaposi’s sarcoma, and bacillary angiomatosis. There is a possibility of recurrence and/or the development of satellite lesions, but these options are less invasive and do not result in significant scarring. Complete excision requiring sutures may lower the recurrence rate and reduce the possibility of bleeding; however, a linear scar will be present. Hemostasis can be obtained by either electrocautery, silver nitrate, or argon laser photocoagulation, as all are shown to be effective. As this is a benign growth, it is important to consider the cosmetic outcome of the therapeutic intervention.

Cryotherapy is also effective. With this modality, patients should be seen within 1 to 2 weeks to assess the response and need for additional treatments. Because the pyogenic granuloma is not completely removed, there is a possibility of recurrence; additionally, no tissue is obtained for sampling.

Vascular lasers also destroy these lesions using selective photothermolysis. Usually multiple treatments are required, and there is no histologic confirmation. Pulsed dye laser has proved to be more successful with smaller lesions. For larger lesions the Nd:YAG laser has been efficacious. Sclerotherapy destroys these vascular lesions and has been reported to have a very high cure rate in experienced hands. Various application schedules of imiquimod 5% have resolved these lesions, presumably owing to its anti-angiogenic properties. Recently, photodynamic therapy has been a modality shown to be effective in the destruction of these lesions with very few adverse events.

Specific investigations

In general, clinical suspicion is very useful in diagnosing pyogenic granulomas, although histologic confirmation is important. Pyogenic granulomas should be differentiated from other vascular lesions, especially bacillary angiomatosis. Amelanotic melanomas may mimic pyogenic granulomas. The remainder of the differential includes angiosarcoma, basal cell carcinoma, and Kaposi’s sarcoma. Because many of the methods described below result in removal, this tissue can be sent to confirm the clinical diagnosis.

Some drugs have been reported to cause pyogenic granulomas. These include oral contraceptives, isotretinoin, acitretin, reverse transcriptase inhibitors, epidermal growth factor inhibitors, systemic 5-fluorouracil, capecitabine, mTOR inhibitors, monoclonal anti-CD20 antibodies, and topical tretinoin. Recently, there have been reports of these lesions arising in both port-wine stains and cherry angiomas when treated with the pulsed dye laser. Rarely eruptive lesions have been reported in response to a drug hypersensitivity reaction.

First-line therapies

image Simple shave excision/curettage with electrocautery of the base A
image Full-thickness skin excision A
image Cryotherapy A
image Silver nitrate cautery D

Comparison of cyrotherapy and curettage for the treatment of pyogenic granuloma: a randomized trial.

Ghodsi SZ, Raziel M, Taheri A, Karami M, Mansoori P, Farnaghi F. Br J Dermatol 2006; 154: 671–5.

Eighty-nine patients were randomized for treatment with either liquid nitrogen cryotherapy or curettage followed by electrodesiccation. Of the 86 patients who completed the study, all had complete resolution of the lesions after one to three sessions (mean 1.42) in the cryotherapy group, and after one to two sessions (mean 1.03) in the curettage group. No scar or residual pigmentation was reported in 57% of the cryotherapy group or in 69% of the curettage group. The authors concluded that although both treatments were safe and effective, curettage should be first-line as fewer treatment sessions were necessary and cosmesis was better.

Second-line therapies

image Pulsed dye B
image CO2 laser B
image Nd:YAG laser B

Treatment of pyogenic granuloma in children with the flashlamp-pumped pulsed dye laser.

Tay YK, Weston WL, Morelli JG. Pediatrics 1997; 99: 368–70.

Twenty-two children with solitary lesions were treated with a vascular-specific (585 nm), pulsed (450 ms) dye laser using a 5 nm spot size with a laser energy of 6–7 J/cm2 without anesthesia. This treatment was successful in 91% and all healed without scarring. Fifteen patients required from two to six treatments at 2-week intervals, and seven required three or more. The two patients who did not respond had larger lesions (0.5–1 cm). No recurrences were reported during the follow-up period (6 months to 3 years). The limitation of this laser modality was that the depth of penetration was only 1 mm.

This can be a useful modality in children, as no anesthesia is required and there is minimal scarring. The drawback is that no tissue is obtained for histology.

Third-line therapies

image Ligation E
image Imiquimod 5% C
image Sclerotherapy D
image Photodynamic therapy D
image Intralesional corticosteroids E
image Intralesional bleomycin E
image Topical phenol E

Pyogenic granuloma in ten children treated with topical imiquimod.

Tritton SM, Smith A, Wong LC, Zagarella S, Fischer G. Pediatr Dermatol 2009; 26: 269–72.

Ten healthy children with a mean age of 2.5 years were instructed to apply imiquimod 5% either once a day, twice a day, or three times per week depending on the clinical response. They were assessed either weekly or bi-weekly. All lesions were located on the face (3–6 mm) and local erythema was unanimously observed. Three had no residual disease while five had either small hypopigmented or erythematous lesions which were continuing to improve at the completion of the study. No systemic side effects were reported.

The authors suggest a trial of three times per week initially, increasing to daily if tolerated for up to 2 months. Treatment should be discontinued 1 week after complete disappearance of the lesion. This appears a reasonable alternative to surgical excision.

Photodynamic therapy with 5-aminolevulinic acid intralesionsal injection for pyogenic granuloma.

Lee DJ, Kim EH, Jang YH, Kim YC. Arch Dermatol 2012; 148: 126–8.

Fourteen pyogenic granulomas were injected (26-gauge needle) with 0.3 mL/cm3 of 5-aminolevulinic acid, 20% solution followed by occlusion with polyurethane film. The lesions were then illuminated with red light (600–720 nm, light dose 100 J/cm2 and fluence 100 mW/cm2). Eleven patients showed a marked response and had no recurrence at 1-year follow-up. One patient showed moderate response (lesion was on the lip) and two did not respond (lesions large >1 cm). Only three patients complained of perilesional swelling.

The authors felt that this treatment can be an alternative to standard therapy especially in patients with small lesions who refuse surgery. It is important to consider the location and size of the lesion. In addition, intralesional was suggested to be more effective than topical application of the photosensitizer.

Topical phenol as a conservative treatment for periungal pyogenic granuloma.

Losa Iglesias ME, Becerro de Bengoa Vallejo R. Dermatol Surg 2010; 36: 675–8.

A report of 18 patients treated with a 98% phenol solution after a thorough cleansing of the area. The phenol was applied to the lesion in three applications of 1 minute each, consecutively. The entire tumor and a small surrounding area turned white. The areas were then treated with 10% silver sulfadiazine and 10% povidone iodine and wrapped in sterile gauze. The frequency of additional treatments varied based on size. At the 14-week endpoint, all lesions had resolved. The treatments were well tolerated with no scarring or adverse events.

This approach is simple to perform, fairly inexpensive, and relatively pain free; however, recurrence is possible and treatment may necessitate frequent office visits.

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Pyogenic granuloma

Danielle M. DeHoratius

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

image

Pyogenic granuloma, also known as a lobular capillary hemangioma, is a common benign vascular growth. It can rapidly appear and is a solitary, erythematous papule. Pyogenic granulomas are often friable and can frequently ulcerate. They most commonly occur in children and young adults. The etiology is unclear, although reactive neovascularization is suspected because of their occurrence at sites of previous trauma. There is no gender or racial predominance. The most common locations are the head and neck region (including the oral mucosa, especially in pregnant women – granuloma gravidarum) and digits. Occasionally, pyogenic granulomas have been found in subcutaneous or intravascular locations. The term pyogenic granuloma, however, is a misnomer, as there is not an infectious or a granulomatous component to these lesions. Over time they can resolve on their own. Dermoscopy of these lesions can be useful but should not substitute histology. The most sensitive and specific pattern is a reddish homogeneous area, white collarette, and white rail lines.

Management strategy

Pyogenic granulomas are most commonly managed by destruction. This can be completed through shave excision with electrocautery to the base, curettage with electrodesiccation, or cryotherapy. Histologic confirmation is beneficial as other disorders may clinically mimic pyogenic granulomas, examples being amelanotic melanoma, Kaposi’s sarcoma, and bacillary angiomatosis. There is a possibility of recurrence and/or the development of satellite lesions, but these options are less invasive and do not result in significant scarring. Complete excision requiring sutures may lower the recurrence rate and reduce the possibility of bleeding; however, a linear scar will be present. Hemostasis can be obtained by either electrocautery, silver nitrate, or argon laser photocoagulation, as all are shown to be effective. As this is a benign growth, it is important to consider the cosmetic outcome of the therapeutic intervention.

Cryotherapy is also effective. With this modality, patients should be seen within 1 to 2 weeks to assess the response and need for additional treatments. Because the pyogenic granuloma is not completely removed, there is a possibility of recurrence; additionally, no tissue is obtained for sampling.

Vascular lasers also destroy these lesions using selective photothermolysis. Usually multiple treatments are required, and there is no histologic confirmation. Pulsed dye laser has proved to be more successful with smaller lesions. For larger lesions the Nd:YAG laser has been efficacious. Sclerotherapy destroys these vascular lesions and has been reported to have a very high cure rate in experienced hands. Various application schedules of imiquimod 5% have resolved these lesions, presumably owing to its anti-angiogenic properties. Recently, photodynamic therapy has been a modality shown to be effective in the destruction of these lesions with very few adverse events.

Specific investigations

In general, clinical suspicion is very useful in diagnosing pyogenic granulomas, although histologic confirmation is important. Pyogenic granulomas should be differentiated from other vascular lesions, especially bacillary angiomatosis. Amelanotic melanomas may mimic pyogenic granulomas. The remainder of the differential includes angiosarcoma, basal cell carcinoma, and Kaposi’s sarcoma. Because many of the methods described below result in removal, this tissue can be sent to confirm the clinical diagnosis.

Some drugs have been reported to cause pyogenic granulomas. These include oral contraceptives, isotretinoin, acitretin, reverse transcriptase inhibitors, epidermal growth factor inhibitors, systemic 5-fluorouracil, capecitabine, mTOR inhibitors, monoclonal anti-CD20 antibodies, and topical tretinoin. Recently, there have been reports of these lesions arising in both port-wine stains and cherry angiomas when treated with the pulsed dye laser. Rarely eruptive lesions have been reported in response to a drug hypersensitivity reaction.

First-line therapies

image Simple shave excision/curettage with electrocautery of the base A
image Full-thickness skin excision A
image Cryotherapy A
image Silver nitrate cautery D