Annulare and Pyogenic Granuloma Clinical Presentation

  • Author: Richard Lichenstein, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: May 22, 2012
 

History

  • Granuloma annulare
    • History should focus on issues regarding diet, weight loss, and/or fever. This will help rule out other potential diagnoses such as trauma, infection, tumor, metabolic bone or skin disease, and inflammatory or autoimmune disease.
    • Children with granuloma annulare are usually otherwise healthy and have the lesions for several months without any other symptoms.
  • Pyogenic granuloma
    • In patients with suspected pyogenic granuloma, history should focus on the onset and associated symptoms of the rash.
    • Query the patient or parents regarding a preceding history of trauma, viral or bacterial infection, pregnancy, or HIV infection.
    • The patient and family should be questioned regarding prior rashes, port wine stain, and prior treatment.
    • The presence or absence of signs such as bleeding or ulceration should be noted.
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Physical

  • Granuloma annulare
    • Children with GA usually present with one or more firm, nontender soft tissue nodules on the extremities, scalp, or forehead.
    • Papules are 1-5 mm in diameter, flesh-colored or slightly pink, and smooth rather than scaly. They are easily distinguished from the lesions of erythema chronicum migrans, which are usually red in color and ring-shaped with central clearing.
    • Lesions may be generalized in children or in immunocompromised patients but are most often found along the extensor aspects of the extremities, in close proximity to joints.
    • Nodules of the scalp or forehead usually are fixed to periosteum and are only minimally mobile. Lesions of the extremities usually are fixed to fascia and are freely mobile.
  • Pyogenic granuloma
    • Physical examination should focus on the location and size of vascular papules, nodules, and peduncles that may be present on the skin or mucous membranes.
    • The presence or absence of bleeding or ulceration should be noted.
    • If present, other rashes should be described.
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Causes

  • Granuloma annulare
    • Etiology of childhood granuloma annulare is unknown.
    • No good evidence supports suggestions that trauma, tuberculosis, streptococcal infection, herpes zoster/varicella, collagen vascular disorder, or diabetes mellitus are causally related to granuloma annulare. There are also weak associations with BCG vaccination; drugs such as allopurinol and zalcitabine; other viral infections such as EBV, HIV, hepatitis C, Parvovirus B19; autoimmune thyroiditis; and malignant conditions. Borrelia has also recently been implicated in one study.[3]
    • There is some evidence to suggest that granuloma annulare is an immunologic disease in the form of delayed type hypersensitivity reaction.
  • Pyogenic granuloma
    • The cause of pyogenic granuloma is unknown.
    • Suggested potential risk factors include pregnancy, birth control pills, bacterial and viral infections, microscopic arteriovenous anastomoses, and angiogenic growth factors, but no good evidence supports any of these as primary causative factors. In one large pediatric series, only 7% had any history of trauma preceding the development of the lesion.
    • Pyogenic granulomas have been reported arising within port wine stains. On rare occasions, lesions have been associated with malignancy.
    • Intraoral lesions can have an appearance and behavior very similar to the appearance and behavior of intraoral Kaposi sarcoma. These lesions may bleed extensively if biopsied; thus, HIV testing may be indicated when patients have intraoral lesions with the appearance of pyogenic granuloma.[4]
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Contributor Information and Disclosures
Author

Richard Lichenstein, MD  Associate Professor, Pediatric Emergency Department, University of Maryland School of Medicine

Richard Lichenstein, MD is a member of the following medical societies: American Academy of Pediatrics and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Edward A Michelson, MD  Associate Professor, Program Director, Department of Emergency Medicine, University Hospital Health Systems of Cleveland

Edward A Michelson, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Mark W Fourre, MD  Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol. Jan 2012;16(1):79-82. [Medline]. [Full Text].

  2. Krishnapillai R, Punnoose K, Angadi PV, Koneru A. Oral pyogenic granuloma-a review of 215 cases in a South Indian Teaching Hospital, Karnataka, over a period of 20 years. Oral Maxillofac Surg. Jan 26 2012;[Medline].

  3. Ziemer M, Grabner T, Eisendle K, Baltaci M, Zelger B. Granuloma annulare - a manifestation of infection with Borrelia?. J Cutan Pathol. Jun 18 2008;[Medline].

  4. Scott PL, Motaparthi K, Krishnan B, Hsu S. Pyogenic granuloma-like Kaposi sarcoma: a diagnostic pitfall. Dermatol Online J. Mar 15 2012;18(3):4. [Medline].

  5. Looney M, Smith KM. Isotretinoin in the treatment of granuloma annulare. Ann Pharmacother. Mar 2004;38(3):494-7. [Medline].

  6. Weber HO, Borelli C, Rocken M, Schaller M. Treatment of disseminated granuloma annulare with low-dose fumaric acid. Acta Derm Venereol. 2009;89(3):295-8. [Medline].

  7. Werchau S, Enk A, Hartmann M. Generalized interstitial granuloma annulare--response to adalimumab. Int J Dermatol. Apr 2010;49(4):457-60. [Medline].

  8. Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. Jan-Feb 2004;21(1):10-3. [Medline].

  9. Arroyo MP. Generalized granuloma annulare. Dermatol Online J. Oct 2003;9(4):13. [Medline].

  10. Dillman AM, Miller RC, Hansen RC. Multiple pyogenic granulomata in childhood. Pediatr Dermatol. Mar 1991;8(1):28-31. [Medline].

  11. Felner EI, Steinberg JB, Weinberg AG. Subcutaneous granuloma annulare: a review of 47 cases. Pediatrics. Dec 1997;100(6):965-7. [Medline].

  12. Grimalt R, Caputo R. Symmetric pyogenic granuloma. J Am Acad Dermatol. Oct 1993;29(4):652. [Medline].

  13. Medlock MD, McComb JG, Raffel C, Gonzalez-Gomez I. Subcutaneous palisading granuloma of the scalp in childhood. Pediatr Neurosurg. 1994;21(2):113-6. [Medline].

  14. Mooney MA, Janniger CK. Pyogenic granuloma. Cutis. Mar 1995;55(3):133-6. [Medline].

  15. Pomeranz AJ, Fairley JA. The systematic evaluation of the skin in children. Pediatr Clin North Am. Feb 1998;45(1):49-63. [Medline].

  16. Scheinfeld NS. Pyogenic granuloma. Skinmed. Jan-Feb 2008;7(1):37-9. [Medline].

  17. Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. Jul 1996;41(7):467-70. [Medline].

  18. Tan HH, Goh CL. Granuloma annulare: a review of 41 cases at the National Skin Centre. Ann Acad Med Singapore. Nov 2000;29(6):714-8. [Medline].

  19. Tay YK, Weston WL, Morelli JG. Treatment of pyogenic granuloma in children with the flashlamp-pumped pulsed dye laser. Pediatrics. Mar 1997;99(3):368-70. [Medline].

 
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