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Pyogenic granuloma
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Pyogenic granuloma (PG), also known as a lobular capillary hemangioma , is a common benign vascular growth. It often develops rapidly into a solitary erythematous papule or polyp. PGs can be friable and hemorrhagic and 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. They have also been reported as a cutaneous adverse effect of various medications. There is no gender or racial predominance. PGs are more common in pregnancy. The most common locations are the head and neck region (including the oral mucosa, especially in pregnant women, known as granuloma gravidarum ) and digits. Rarely, an amelanotic melanoma can be mistaken as a PG, so histology is preferred for isolated lesions where this might be possible, for example, non-pigmented skin of the digit in a darkly pigmented patient. Occasionally, PGs have been found in subcutaneous or intravascular locations. The term PG is a misnomer – there is no infectious or granulomatous component to these lesions.
Management Strategy
Histologic confirmation is beneficial, as other disorders may clinically mimic PGs, examples being amelanotic melanoma, Kaposi sarcoma, and bacillary angiomatosis. Dermoscopy of these lesions can be useful but should not substitute for histology. The most sensitive and specific pattern is a reddish homogeneous area, white collarette, and white rail lines.
Although they can eventually resolve spontaneously, treatment is usually required. Because this is a benign growth, it is important to consider the cosmetic outcome of the therapeutic intervention. PGs are most commonly treated by destruction using shave excision with electrocautery to the base, curettage with electrodesiccation , or cryotherapy. There is a possibility of recurrence and/or the development of satellite lesions, but these options are less invasive than excision 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 electrocautery, silver nitrate, or argon laser photocoagulation.
Vascular lasers also destroy these lesions, although multiple treatments are usually 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 PGs, presumably due to its antiangiogenic properties. Photodynamic therapy has been shown to be effective with very few adverse events.
More recently, topical β-blockers have been reported useful in treating PGs while maintaining ease of application, cosmetic considerations, and reducing adverse events. Additional investigation is necessary to assess its efficacy. It is an important option in younger children as well as delicate cosmetic locations.
First-Line Therapies
Pyogenic granuloma in children
Pagliai KA, Cohen BA. Pediatr Dermatol 2004; 21: 10–3.
A retrospective study of 128 children, including follow-up phone interviews of 76. Of these, 72.3% underwent a shave excision with electrocautery. The second most common treatment was laser therapy (16.9%). Fifty-five percent of the children in the first group reported a subtle scar, and 33% of the CO 2 laser group and 44% of the pulsed dye laser group reported a similar scar. The mean age was 5.9 years old (4 months to 17 years). A eutectic mixture of lidocaine and prilocaine was used topically for 1–2 hours prior to the laser treatments. Intradermal lidocaine was added when the CO 2 laser was used. All patients were pleased with the cosmetic result.
Comparison of cryotherapy and curettage for the treatment of pyogenic granuloma: a randomized trial
Ghodsi SZ, Raziel M, Taheri A, et al. Br J Dermatol 2006; 154: 671–5.
In total, 89 patients were treated 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 curettage should be a first-line therapy as fewer treatment sessions were necessary and cosmesis was better.
Pyogenic granuloma – the quest for optimum treatment audit of treatment of 408 cases
Giblin AV, Clover AJ, Athanassopoulos A, et al. Plast Reconstruct Aesthet Surg 2007; 60: 1030–5.
A retrospective study of 408 cases analyzed between 1994 and 2004. The excision and direct closure group had the fewest recurrences.
Cryotherapy in the treatment of pyogenic granuloma
Mirshams M, Daneshpazhooh M, Mirshekari A, et al. J Eur Acad Dermatol Venereol 2006; 20: 788–90.
A prospective study of 135 patients treated with liquid nitrogen cryotherapy using a cotton-tipped applicator. Patients required anywhere from one to four treatments (mean 1.58). All patients had complete resolution, with 96.2% occurring after three treatments. Minor scars were reported in 11.8%, and 5.1% had hypopigmentation.
These authors report that cryotherapy should be considered first-line therapy as it is an easy and inexpensive technique; however, the main limitation is a lack of histologic confirmation.
Treatment of pediatric pyogenic granulomas using β-adrenergic receptor antagonists
Lee LW, Goff KL, Lam JM, et al. Pediatric Dermatol 2014; 31: 203–7.
A series of seven cases of cutaneous and mucosal PGs successfully treated with oral or topical β-blockers. Three of the seven had failed previous modalities. In most of the cases, topical timolol was applied three times daily and either a complete or partial response was achieved. A partial response was achieved as early as 6 weeks and complete resolution took anywhere from 2 to 6 months.
An excellent option when destruction procedures either failed or are not desirable.
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