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Annulare and Pyogenic Granuloma Treatment & Management

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

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. Intravenous access may be indicated if hemorrhage is severe.

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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.

Although there are numerous case reports of successful treatment of granuloma annulare, including medical and phototherapy options, randomized, controlled clinical trials are needed.[7]

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.

A meta-analysis demonstrates that surgical excision offers the lowest overall recurrence rates (2.94%) and cryotherapy offered the lowest overall recurrence rate (1.62%).[8] If surgical excision and closure are not performed, cauterization with silver nitrate should be the first-line treatment.

In pediatrics, a case series has demonstrated the use of oral or topical beta-blockers to be a potential noninvasive treatment of mucosal pyogenic granulomas.[9]

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Consultations

If diagnosis is unproven, follow-up care with a dermatologist is indicated.

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Complications

In cases of granuloma annulare without other etiology of the subcutaneous nodules, no complications are encountered.

The principal complication associated with pyogenic granuloma is hemorrhage, which can be significant and can require intervention.

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Long-Term Monitoring

Further outpatient care is needed to follow the progress of lesions because as many as 20% of children with granuloma annulare experience recurrence.

Local recurrence after treatment of pyogenic granuloma by any method is not uncommon. In a one series, most of patients with uncomplicated pyogenic granuloma were treated with single shave excision and electrocautery, with no recurrences.[10]

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Contributor Information and Disclosures
Author

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

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

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

Disclosure: Nothing to disclose.

References
  1. Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012 Jan. 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. 2012 Jan 26. [Medline].

  3. Spicuzza L, Salafia S, Capizzi A, Vitaliti G, Rotolo N, Leonardi S, et al. Granuloma annulare as first clinical manifestation of diabetes mellitus in children: a case report. Diabetes Res Clin Pract. 2012 Mar. 95(3):e55-7. [Medline].

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

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

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

  7. Thornsberry LA, English JC 3rd. Etiology, diagnosis, and therapeutic management of granuloma annulare: an update. Am J Clin Dermatol. 2013 Aug. 14(4):279-90. [Medline].

  8. Lee J, Sinno H, Tahiri Y, Gilardino MS. Treatment options for cutaneous pyogenic granulomas: a review. J Plast Reconstr Aesthet Surg. 2011 Sep. 64(9):1216-20. [Medline].

  9. Wine Lee L, Goff KL, Lam JM, Low DW, Yan AC, Castelo-Soccio L. Treatment of pediatric pyogenic granulomas using β-adrenergic receptor antagonists. Pediatr Dermatol. 2014 Mar-Apr. 31 (2):203-7. [Medline].

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

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

  12. 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].

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

 
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