Annulare and Pyogenic Granuloma

Updated: Jul 14, 2016
  • Author: Richard Lichenstein, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
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Overview

Background

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

Granuloma annulare. Courtesy of Wikimedia Commons Granuloma annulare. Courtesy of Wikimedia Commons (Mierlo at English Wikipedia).

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. See the image below.

Pyogenic granulomas are usually solitary lesions. Pyogenic granulomas are usually solitary lesions. The fingers and hands are common locations for these to develop. A history of minor trauma at the site shortly before development of the lesion is frequent.
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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. [1]

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Epidemiology

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.

International

Pyogenic granuloma was 50% of reactive lesions compared to 21-26% reactive lesions in a local South Indian population between 1989-2009. [2]

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.

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Prognosis

Granuloma annulare

The prognosis of granuloma annulare is excellent, as the lesions usually regress spontaneously. Fifty to 70% with the localized type resolve after 1-2 years. The generalized type is less likely to resolve spontaneously. 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

The prognosis of pyogenic granuloma is also excellent. Pyogenic granuloma is a benign vascular tumor, mostly occurring in childhood. Lesions may bleed and ulcerate.

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Patient Education

Reassurance and referral are the principal and essential steps in patient education.

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