Synonyms: lobular capillary haemangioma

Pyogenic granulomata are common benign vascular lesions of the skin and mucosa. They are neither infective, purulent or granulomatous as the name might suggest - rather a reactive inflammatory mass of blood vessels and a few fibroblasts within the dermis of the skin.

Aetiology

• Not fully understood: rapid growth occurs in response to an unknown stimulus that triggers endothelial proliferation and angiogenesis.
• Trauma and burns can provoke the sequence but frequently there is no identifiable cause.
• Other suggested causes include viral oncogenes, hormonal influences (pregnancy, oral contraceptive pill) and cytogenetic abnormalities.
• They have also been associated with certain medications:
  • Systemic¹ and topical retinoids
  • Indinavir (a protease inhibitor)
  • Chemotherapy agents such as fluorouracil and capecitabine

Epidemiology

• Mean age for presentation is 6-7 years old. Thereafter, decrease in incidence with age. They represent 0.5% of skin nodules in children.
• More common in women due to frequent formation on the gingiva during pregnancy (pregnancy tumour or epulis gravidarum) - occur in up to 5% pregnancies.²

Visual appearance

• Solitary, red, purple or yellow papule or nodule arising from normal skin.
• Size varies from a few millimetres in diameter to several centimetres.
• Polypoid appearance - often develop a stalk or 'collarette' of scale at the base.
• Friable lesion - often seen to be bleeding, crusted or ulcerated.

Presentation³

• Rapid eruption and growth over a few weeks.
• Most commonly occur on the head, neck and extremities (particularly fingers).
• They occasionally occur on the external genitalia.⁴
• In pregnancy, most likely to occur on the maxillary intraoral mucosal surface during the second and third trimesters.
• Rarely multiple satellite lesions may develop - especially in adolescents and young adults after prior attempts to remove the original lesion.

Differential diagnosis⁵

Includes:

• Basal cell carcinoma
• Campbell de Morgan spot
• Glomus tumour
• Congenital haemangioma
• Kaposi's sarcoma
• Malignant melanoma
• Metastatic carcinoma of the skin
• Spitz naevus
• Squamous cell carcinoma

Primary Care management

• Most patients seek help because of the bleeding associated with the lesion.
• Treatment options include curettage and cautery, shave excision, excision with primary closure and laser therapy.
• Cryotherapy may work but does not provide a histological specimen for diagnosis.
• All specimens should be sent for histological confirmation.

When to refer

• For assistance with diagnosis and removal.
• Following a recurrence.
• Where a nodular melanoma is suspected.

Complications

Pain and bleeding are the most usual problems associated with this lesion.

Prognosis⁵

• Pyogenic granulomata are benign lesions.
• Untreated lesions will atrophy eventually but only a minority will spontaneously involute within six months.
• Recurrence rates following treatment can be quite high - 40-50% regardless of treatment modality.
• Pregnancy tumours tend to regress spontaneously following childbirth so treatment should be postponed accordingly.