Pyogenic Granuloma (Lobular Capillary Hemangioma)

Updated: Apr 10, 2017
  • Author: Joseph C Pierson, MD; Chief Editor: William D James, MD  more...
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Overview

Background

Pyogenic granuloma (lobular capillary hemangioma [1] ) is a relatively common benign vascular lesion of the skin and mucosa whose exact cause is unknown. Also see the Medscape Drugs & Diseases article Oral Pyogenic Granuloma.

Pyogenic granulomas are misnamed; they are neither infectious nor granulomatous. The lesion usually occurs in children and young adults as a solitary, glistening red papule or nodule that is prone to bleeding and ulceration. Pyogenic granulomas typically evolve rapidly over a period of a few weeks, most often on the head, neck, extremities, and upper trunk.

Pyogenic granuloma often arises in pregnancy (or rarely with oral contraceptive usage), particularly on the gingiva or elsewhere in the oral mucosa, and then is termed the "pregnancy tumor."

Other pyogenic granuloma variants that have been well documented include the disseminated, subcutaneous, intravenous, and medication-induced (for example, retinoid, antiretroviral, and oncologic agent) subtypes.

Removal of pyogenic granuloma is indicated to alleviate any bleeding, discomfort, cosmetic distress, and diagnostic uncertainty. A number of malignant tumors may clinically mimic pyogenic granuloma, making histopathologic confirmation important if the presentation is atypical.

Aside from cutaneous and oral lesions, pyogenic granuloma has been reported throughout the gastrointestinal tract and upper airway, at various ocular locations, the central nervous system, the bladder, and the internal vasculature. This article discusses only cutaneous and oral involvement.

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Pathophysiology

The precise mechanism for the development of pyogenic granuloma (lobular capillary hemangioma) is unknown. Trauma, hormonal influences, certain medications, viruses, underlying microscopic arteriovenous malformations, the production of angiogenic growth factors, and cytogenetic abnormalities have all been postulated to play a role. The overexpression of transcription factors P-ATF2 and STAT3 also may play a role in tumorigenesis. [2] Endothelial nitric oxide synthases (eNOS), CD34, and CD105/endoglin expression are markers of angiogenesis in pyogenic granulomas. [3, 4] . Tissue injury may trigger pathologic angiogenesis driven by FLT4, a tyrosine-kinase receptor, and the nitric acid pathway. [5] COX-2 and IL-10 may be involved in the etiopathogenesis of oral pyogenic granulomas. [6]  BRAF and RAS mutations have been identified, suggesting a true neoplastic process. [7, 8]

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Epidemiology

Frequency

Pyogenic granuloma is relatively common, representing 0.5% of all skin nodules in children. [9] The pregnancy tumor variant of pyogenic granuloma occurs in up to 5% of pregnancies. [10]  International frequency for pyogenic granuloma is likely similar to that of the United States.

Race

The frequency of pyogenic granuloma appears to be similar in all races.

Sex

Pyogenic granulomas are equally prevalent in male and female patients, though oral mucosal lesions are twice more common in females, likely due to the pregnancy tumor phenomenon. [11]

Age

Pyogenic granuloma is rare in children younger than 6 months. The peak age of onset for cutaneous lesions is the second decade of life. [11] For patients younger than 17 years, the mean age of presentation has been reported as 6.7 years. [9] Aside from those lesions occurring in pregnancy, the frequency declines linearly with age in adulthood. Also see the Medscape article, Pediatric Pyogenic Granuloma.

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Prognosis

Pyogenic granuloma is a benign lesion; however, discomfort and bleeding occasionally may be significant. The latter may rarely be severe enough to cause anemia. [12]

Lesions that recur despite repeated excisions can be particularly problematic. Pyogenic granulomas can recur regardless of the therapeutic modality used. A missed foreign body was the culprit in one case of a recurrent, intractable pyogenic granuloma. [13] Among surgical options, full-thickness skin excision appears to yield the lowest chance of recurrence (2.94%). [14]  

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Patient Education

If a clear provoking traumatic factor is causing the pyogenic granuloma, it should be avoided. Instruct patients to avoid retinoids if their case can be attributed to such agents.

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