eMedicine Specialties > Emergency Medicine > Dermatology

Granuloma, Annulare and Pyogenic

Author: Richard Lichenstein, MD, Associate Professor, Pediatric Emergency Department, University of Maryland School of Medicine
Contributor Information and Disclosures

Updated: Sep 18, 2008

Introduction

Background

Granuloma annulare (GA) is a benign self-limited dermatosis characterized by a raised annular configuration.

Pyogenic granuloma (PG) is misnamed, being neither pyogenic nor granuloma. It is a benign, acquired, vascular tumor of the skin and mucous membrane that appears as a rapidly growing vascular papule or nodule. Sometimes it appears at the site of a previous penetrating injury. PG is often observed in infancy and childhood but also may be observed in adults, particularly in pregnant women.

Pathophysiology

Granuloma annulare may be localized, generalized, perforating, or subcutaneous. Lesions of the first 3 presentations have similar appearances, but each one follows a distinctive clinical course. Subcutaneous granuloma annulare appears differently, as it is a disease of childhood in which deep dermal or subcutaneous nodules lie on or near the periosteum and are distributed on the feet, lower legs, fingers, hands, forearms, scalp, and forehead.

Pyogenic granuloma is a disorder of angiogenesis whose underlying etiology remains unknown. A predilection exists for the head and neck, although lesions may appear on any part of the body. Purplish, pulpy, vascular lesions of pyogenic granuloma often involve the gum and other mucous membranes of the mouth.

Frequency

United States

Granuloma annulare is most common in children and young adults.

Solitary pyogenic granuloma is common and represents 0.5% of all skin nodules in children.

Mortality/Morbidity

• Granuloma annulare is a self-limited cosmetic disease without any systemic medical complications. On rare occasions, it may involve fascia and tendons and may cause sclerosis, lymphedema, and deformities such as joint ankylosis. Granuloma annulare has been epidemiologically linked to diabetes mellitus, necrobiosis lipoidica diabeticorum, and rheumatoid nodules.
• Pyogenic granuloma is a benign vascular tumor, mostly occurring in childhood. Lesions may bleed and ulcerate.

Race

• Granuloma annulare is believed to affect patients without respect to racial heritage.
• Pyogenic granuloma may affect white populations more than other racial groups, but this is not well proven and the observation may reflect sampling bias.

Sex

Granuloma annulare has a slight tendency toward females.

• In granuloma annulare, females are slightly more affected than males.
• In pyogenic granuloma, the male-to-female ratio is 3:2.

Age

• More than two thirds of patients with granuloma annulare experience disease onset when younger than 30 years. In pediatric patients with granuloma annulare, the age of onset ranges from 1-14 years, with a mean of 4 years. The localized type of granuloma annulare occurs primarily in young children, whereas the generalized form is seen in patients younger than 10 years or older than 40 years.
• Approximately one half of cases of pyogenic granuloma occur within the first 5 years of life.

Clinical

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.

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.

For a CME/CE activity, see Examining the Ears, Nose, and Oral Cavity in the Older Patient.

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.¹
  • 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.

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