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Synonyms: lobular capillary haemangioma
Pyogenic granulomata are common benign vascular lesions of the skin and mucosa. They are not 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.
- 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:
- Mean age for presentation is 6-7 years. Thereafter, there is a decrease in incidence with age. They represent 0.5% of skin nodules in children.
- They are more common in women, due to frequent formation on the gingiva during pregnancy (pregnancy tumour, or epulis gravidarum) - occurring in up to 5% of pregnancies.
- 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 - they often develop a stalk or 'collarette' of scale at the base.
- Friable lesion - they are often seen to be bleeding, crusted or ulcerated.
Pyogenic granuloma images
- Rapid eruption and growth over a few weeks.
- Most commonly, they occur on the head, neck and extremities (particularly the fingers).
- They occasionally occur on the external genitalia.
- In pregnancy, they are most likely to occur on the maxillary intraoral mucosal surface during the second and third trimesters.
- They have also been reported on the labial mucosa in men.
- Rarely, multiple satellite lesions may develop - especially in adolescents and young adults after prior attempts to remove the original lesion.
- 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
Some advocate sending all lesions for histological confirmation, because the vascular nature of the lesion makes dermoscopy unreliable. However, there may be occasions on which dermoscopy may be considered sufficient (eg, typical appearance in a very young child).
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.
- One study reported the use of sclerotherapy employing sodium tetradecyl sulfate as the sclerosant. As with cryotherapy, this technique does not provide a histological specimen. Moreover, sodium tetradecyl sulfate is only licensed for the treatment of varicose veins in the UK, so the usual considerations concerning the use of unlicensed medicines apply.
When to refer
- For assistance with diagnosis and removal
- Following a recurrence
- Where a nodular melanoma is suspected
Pain and bleeding are the most usual problems associated with this lesion.
- 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 common regardless of treatment modality.
- Pregnancy tumours tend to regress spontaneously following childbirth so treatment should be postponed accordingly.
Further reading & references
- Murthy SC, Nagaraj A; Pyogenic granuloma. Indian Pediatr. 2012 Oct;49(10):855.
- Pyogenic Granuloma, DermNet NZ
- Badri T, Hawilo AM, Benmously R, et al; Acitretin-induced pyogenic granuloma. Acta Dermatovenerol Alp Panonica Adriat. 2011;20(4):217-8.
- Teknetzis A, Ioannides D, Vakali G, et al; Pyogenic granulomas following topical application of tretinoin. J Eur Acad Dermatol Venereol. 2004 May;18(3):337-9.
- Colson AE, Sax PE, Keller MJ, et al; Paronychia in association with indinavir treatment. Clin Infect Dis. 2001 Jan;32(1):140-3.
- Curr N, Saunders H, Murugasu A, et al; Multiple periungual pyogenic granulomas following systemic 5-fluorouracil. Australas J Dermatol. 2006 May;47(2):130-3.
- Paul LJ, Cohen PR; Paclitaxel-associated subungual pyogenic granuloma: report in a patient with breast cancer receiving paclitaxel and review of drug-induced pyogenic granulomas adjacent to and beneath the nail. J Drugs Dermatol. 2012 Feb;11(2):262-8.
- Durgun M, Selcuk CT, Ozalp B, et al; Multiple disseminated pyogenic granuloma after second degree scald burn: a rare two case. Int J Burns Trauma. 2013 Apr 18;3(2):125-9. Print 2013.
- Kamal R, Dahiya P, Puri A; Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012 Jan;16(1):79-82. doi: 10.4103/0973-029X.92978.
- Jafarzadeh H, Sanatkhani M, Mohtasham N; Oral pyogenic granuloma: a review. J Oral Sci. 2006 Dec;48(4):167-75.
- Arikan DC, Kiran G, Sayar H, et al; Vulvar pyogenic granuloma in a postmenopausal woman: case report and review of the literature. Case Rep Med. 2011;2011:201901. doi: 10.1155/2011/201901. Epub 2011 Sep 8.
- Ravi V, Jacob M, Sivakumar A, et al; Pyogenic granuloma of labial mucosa: A misnomer in an anomolous site. J Pharm Bioallied Sci. 2012 Aug;4(Suppl 2):S194-6. doi: 10.4103/0975-7406.100269.
- Wolff K et al; Disorders of Melanocytes; Dermatologic Guide, 2007
- Zaballos P, Carulla M, Ozdemir F, et al; Dermoscopy of pyogenic granuloma: a morphological study. Br J Dermatol. 2010 Dec;163(6):1229-37. doi: 10.1111/j.1365-2133.2010.10040.x.
- Lacarrubba F, Caltabiano R, Micali G; Dermoscopic and histological correlation of an atypical case of pyogenic granuloma. Pediatr Dermatol. 2013 Jul;30(4):499-501. doi: 10.1111/pde.12123. Epub 2013 Mar 14.
- Pyogenic granuloma, Primary Care Dermatology Society, 2012
- Sacchidanand S, Purohit V; Sclerotherapy for the treatment of pyogenic granuloma. Indian J Dermatol. 2013 Jan;58(1):77-8. doi: 10.4103/0019-5154.105317.
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Dr Chloe Borton
Dr Laurence Knott
Prof Cathy Jackson