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Pediatric Pyogenic Granuloma Clinical Presentation

  • Author: Brian Keene, DO; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Feb 25, 2016
 

History

Patients with pyogenic granulomas (PGs) usually seek care because the lesion has grown rapidly and bleeds easily. Patients or parents may be concerned because the lesion bleeds with little or no trauma; they are frequently concerned that the rapid growth and bleeding may indicate a malignancy.

Important questions include the following:

  • Does the history include trauma at the site prior to development of the lesion? Pyogenic granulomas may occur following minor physical trauma or burns.
  • How long has the lesion been present? Most pyogenic granulomas develop rapidly. The mean duration at the time of diagnosis is approximately 3 months. If the lesion has been present longer than 6 months, the possibility of cutaneous malignancy increases.
  • Does the lesion bleed easily? Almost all pyogenic granulomas bleed easily. If the lesion does not bleed with light rubbing, a diagnosis of pyogenic granuloma is unlikely.
  • What therapy has been used recently? Nevi, warts, or other lesions may have been treated with caustic agents or cryotherapy prior to referral. Such therapy may markedly change the appearance of the original lesion, causing it to mimic a pyogenic granuloma.
  • Is the patient pregnant? Oral pyogenic granulomas can develop during or just after the first trimester of pregnancy. Examine and properly identify these lesions of pregnancy to avoid misdiagnosis and overtreatment. These lesions are not generally harmful in pregnancy; however, induction of labor due to uncontrollable bleeding from a gingival lesion has been reported.[18, 19, 20, 21, 22, 23]
  • Has the lesion recurred after surgical treatment? If so, was it excised and the skin closed primarily or was it treated with shave removal and electrodesiccation of the base? Pyogenic granulomas may recur. This is more likely when they are incompletely removed, but recurrence is also possible after apparently complete removal. Pyogenic granulomas are more likely to recur after shave removal and electrodesiccation of the base than after surgical excision.
  • Has the patient taken oral retinoid therapy (isotretinoin [Accutane]) recently? Facial pyogenic granuloma–like lesions during isotretinoin therapy have been reported.
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Physical

Pyogenic granulomas (PGs) appear as smooth firm nodules, with or without crusts, and they may have a bright or dusky red color. They are usually solitary, well circumscribed, dome shaped, 1-10 mm in diameter, and sessile or pedunculated.

In children, pyogenic granulomas are most commonly located on the head and neck (62.4%) and, in order of decreasing frequency, on the trunk (19.7%), upper extremity (12.9%), and lower extremity (5%). Most (88.2%) occur on the skin, and the rest involve mucous membranes of the oral cavity and conjunctivae.

In pregnant women, pyogenic granulomas are most often found on the gingival mucosa[20, 24] but they have been known to appear in nonoral areas such as the fingers and inguinal crease.

Pyogenic granulomas may occur within a port-wine stain; the presence of a vascular birthmark in the region of the pyogenic granuloma may be significant.

Amelanotic melanoma may closely mimic a pyogenic granuloma in appearance. Closely examine the skin immediately adjacent to the lesion for any pigmentary irregularity.

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Causes

Originally, pyogenic granulomas (PGs) were thought to be caused by bacterial infection; the etiology has yet to be determined. Postulated etiologies include viral, hormonal, and, more recently, angiogenic factors.

Pyogenic granulomas have been evaluated for the presence of human papillomavirus (HPV) because warts occur in similar age groups and sites. Lesions were tested for HPV 6, 11, 16, 31, 33, 35, 42, and 58. No viruses were present.

Recurrent pyogenic granuloma with satellitosis is an uncommon variant. In one patient with recurrent pyogenic granuloma with satellitosis, Warthin-Starry staining of the lesions revealed clumps of dark bacilli as found in patients with bacillary angiomatosis.[5] An indirect immunofluorescence assay showed elevated immunoglobulin G antibodies against Bartonella (Rochalimaea) henselae. The patient did not present an obvious risk for human immunodeficiency virus (HIV) infection or immunosuppression; no antibodies against HIV-1 and HIV-2 were found. Recurrent pyogenic granulomas with satellitosis may be a localized variant of bacillary angiomatosis.

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Contributor Information and Disclosures
Author

Brian Keene, DO Resident Physician, Department of Family Medicine, Martin Army Community Hospital

Disclosure: Nothing to disclose.

Coauthor(s)

Clark H Cobb, III, MD Assistant Professor of Family Medicine, Uniformed Services University of Health Sciences; Assistant Clinical Professor of Family Medicine, Philadelphia College of Osteopathic Medicine, Georgia Campus; Affiliate Faculty, Family Medicine Residency Program, Columbus Regional Medical Center; Lecturer, Hughston Sports Medicine Clinic

Clark H Cobb, III, MD is a member of the following medical societies: American Academy of Family Physicians, Uniformed Services Academy of Family Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, American Osteopathic Association

Disclosure: Nothing to disclose.

Brett Steinberg, DO Primary Care/Internal Medicine, Staff Physician, US Army Medical Activity, Bavaria

Brett Steinberg, DO is a member of the following medical societies: American Osteopathic Association

Disclosure: Nothing to disclose.

Acknowledgements

Mark A Crowe, MD Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine

Mark A Crowe, MD is a member of the following medical societies: American Academy of Dermatology and North American Clinical Dermatologic Society

Disclosure: Nothing to disclose.

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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.
Pyogenic granulomas usually bleed with little or no trauma. This patient shows a positive bandage sign. Because the lesions bleed so easily, patients frequently present with a bandage covering the site.
Pyogenic granulomas usually have a distinct margin that consists of a rim of keratin (dry skin). Notice the moist area of skin produced by the bandage, which was removed shortly before the photograph was taken.
Pyogenic granulomas may be pedunculated and quite large. An area of necrosis is also common.
Pyogenic granulomas may occur at various sites. More than 60% of all lesions develop on the head and neck.
Unlike pyogenic granulomas, cherry angiomas such as these are slow to develop, do not bleed easily, are frequently multiple, are more commonly found on the trunk, and seldom have a history of prior trauma.
Several malignant tumors may mimic pyogenic granulomas. This lesion is a squamous cell carcinoma. Amelanotic melanomas (little or no overt pigment) are also included in the differential diagnosis. These tumors are usually slower growing than pyogenic granulomas and are uncommon in children. Tissue removed as part of the treatment process should be sent for histopathologic examination to confirm the diagnosis.
Small pyogenic granuloma.
Histologic image showing epidermal erosion and crusting, thinned epidermis, vascular proliferation, and mixed inflammation with lymphocytes, histiocytes, and neutrophils. Courtesy of Medscape Dermatology.
 
 
 
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