eMedicine Specialties > Emergency Medicine > Dermatology
Granuloma, Annulare and Pyogenic: Treatment & Medication
Updated: Sep 18, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Granuloma annulare: Prehospital care is not a consideration for patients with granuloma annulare, which is a nuisance lesion.
- Pyogenic granuloma
- Patients with pyogenic granuloma may present with acute bleeding from the vascular lesions, particularly when they are intraoral.
- In the prehospital setting, bleeding should be controlled by direct pressure, and the airway should be secured if necessary.
- IV access may be indicated if hemorrhage is severe.
Emergency Department Care
- Granuloma annulare
- Granuloma annulare rarely requires any treatment since spontaneous resolution is common.
- Medical and surgical interventions should be avoided unless absolutely necessary.
- Pyogenic granuloma
- For patients who present with hemorrhage, bleeding often may be controlled with direct pressure.
- A vasoconstrictor packing (eg, cocaine or tetracaine with adrenaline) sometimes may be needed.
- When bleeding is refractory or recurrent, sclerotherapy by direct injection of 1-2 mL of 1% sodium tetradecyl sulfate into the vascular plexus is usually effective and may even provide a definitive cure.
- Compress the lesion for 15 minutes following injection. Sclerotherapy usually is necessary in order to allow time for the tumor vessels to go into spasm.
- Effective treatment includes excision (although this may be difficult if the lesion is extensive), electrodesiccation, curettage, chemical cauterization, and injection sclerotherapy. Carbon dioxide and argon lasers have been used successfully for superficial cases of pyogenic granuloma. Pulsed-dye laser also has been shown effective in the treatment of pyogenic granulomas when the lesion is superficial and of less than 0.5 cm thickness. Advantages of excision and electrocautery are ease of use and lack of recurrences according to one recent study in children.
Consultations
- If diagnosis is unproven, follow-up care with a dermatologist is indicated.
Medication
Granuloma annulare
Medical treatments such as corticosteroids, potassium iodide, dapsone, niacinamide, chlorambucil, and isotretinoin have been tried, but none has been shown efficacious. Other treatments include liquid nitrogen cryotherapy, oral and topical PUVA photochemotherapy, UVA1 phototherapy, and cyclosporin. Isotretinoin should be reserved for patients with disseminated or refractory GA because of potential serious toxicity.2
Corticosteroids
Used for their potent anti-inflammatory activity.
Triamcinolone acetonide (Aristospan)
Treats inflammatory lesions that are responsive to steroids. Decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult
2.5-40 mg intralesionally (10 mg/mL or 40 mg/mL solutions) and repeat prn
Pediatric
Administer as in adults
Coadministration with barbiturates, phenytoin, and rifampin decreases effects of triamcinolone
Documented hypersensitivity; fungal, viral, and bacterial skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation of glucocorticoids may cause adrenal crisis
Retinoids
Isotretinoin may have proliferative and inhibitory effects on collagen synthesis that may ameliorate symptoms associated with GA.
Isotretinoin (Amnesteem, Claravis, Sotret)
Has been used as chemoprophylaxis of skin cancers
Adult
20-40 mg PO qd; some reports suggest 0.5-1 mg/kg/d PO
Pediatric
Not established
Toxicity may occur with vitamin A coadministration; pseudotumor cerebri or papilledema may occur when coadministered with tetracyclines; isotretinoin may reduce plasma levels of carbamazepine
Documented hypersensitivity
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May decrease night vision; inflammatory bowel disease may occur; may be associated with development of hepatitis; occasional exaggerated healing response of acne lesions (excessive granulation with crusting) may occur
Diabetic patients may experience problems in controlling their blood sugar while on isotretinoin; avoid exposure to UV light or sunlight until tolerance achieved; discontinue treatment if rectal bleeding, abdominal pain, or severe diarrhea occur; mood swings or depression may occur; caution if history of depression
More on Granuloma, Annulare and Pyogenic |
| Overview: Granuloma, Annulare and Pyogenic |
| Differential Diagnoses & Workup: Granuloma, Annulare and Pyogenic |
 Treatment & Medication: Granuloma, Annulare and Pyogenic |
| Follow-up: Granuloma, Annulare and Pyogenic |
| References |
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References
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].
Looney M, Smith KM. Isotretinoin in the treatment of granuloma annulare. Ann Pharmacother. Mar 2004;38(3):494-7. [Medline].
Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. Jan-Feb 2004;21(1):10-3. [Medline].
Arroyo MP. Generalized granuloma annulare. Dermatol Online J. Oct 2003;9(4):13. [Medline].
Dillman AM, Miller RC, Hansen RC. Multiple pyogenic granulomata in childhood. Pediatr Dermatol. Mar 1991;8(1):28-31. [Medline].
Felner EI, Steinberg JB, Weinberg AG. Subcutaneous granuloma annulare: a review of 47 cases. Pediatrics. Dec 1997;100(6):965-7. [Medline].
Grimalt R, Caputo R. Symmetric pyogenic granuloma. J Am Acad Dermatol. Oct 1993;29(4):652. [Medline].
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].
Mooney MA, Janniger CK. Pyogenic granuloma. Cutis. Mar 1995;55(3):133-6. [Medline].
Pomeranz AJ, Fairley JA. The systematic evaluation of the skin in children. Pediatr Clin North Am. Feb 1998;45(1):49-63. [Medline].
Scheinfeld NS. Pyogenic granuloma. Skinmed. Jan-Feb 2008;7(1):37-9. [Medline].
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].
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].
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].
Further Reading
Keywords
granuloma annulare, pyogenic granuloma, skin nodule, GA, dermatosis, PG, vascular tumor of skin and mucous membrane, papule, nodule, peduncle, subcutaneous GA, self-limited dermatosis, disorder of angiogenesis, sclerosis, lymphedema, joint ankylosis, necrobiosis lipoidica diabeticorum, rheumatoid nodules, benign vascular tumor
