Pyogenic granuloma

Published on 18/03/2015 by admin

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Last modified 18/03/2015

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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

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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

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