eMedicine Specialties > Pediatrics: General Medicine > Dermatology

Pyogenic Granuloma

Author: Mark A Crowe, MD, Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine
Coauthor(s): Brett Steinberg, DO, Staff Physician, Department of Internal Medicine, Walter Reed Army Medical Center
Contributor Information and Disclosures

Updated: Oct 13, 2009

Introduction

Background

Pyogenic granulomas (PGs) are benign vascular lesions that occur most commonly on the acral skin of children.1 The term pyogenic granuloma is a misnomer. Originally, these lesions were thought to be caused by bacterial infection; however, the etiology has not been determined. The histopathologic appearance is fairly characteristic; the lesion is, in fact, a lobular capillary hemangioma.

Recognition of pyogenic granuloma as a clinically polypoid or exophytic circumscribed lesion is of importance to the clinician and pathologist because this feature distinguishes pyogenic granulomas from most malignant vascular tumors. Although pyogenic granulomas may be multiple (especially on the skin) and necrosis is common, invasion of adjacent structures is not observed. The lesions grow rapidly and are extremely vascular, frequently bleeding either spontaneously or after minor trauma. They are usually easily treated with surgical removal but may recur.

Uncommon variants include pyogenic granuloma with satellitosis,2,3,4 intravenous pyogenic granulomas,5 subcutaneous pyogenic granulomas,6,7 and eruptive pyogenic granulomas.8,9 Satellite lesions of smaller pyogenic granulomas may develop at the same time as the primary lesion or may occur after attempted treatment of the primary lesion.

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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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.


Pyogenic granulomas usually bleed with little or ...

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.

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Pyogenic granulomas usually bleed with little or ...

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 margi...

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.

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Pyogenic granulomas usually have a distinct margi...

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...

Pyogenic granulomas may be pedunculated and quite large. An area of necrosis is also common.

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Pyogenic granulomas may be pedunculated and quite...

Pyogenic granulomas may be pedunculated and quite large. An area of necrosis is also common.


Pyogenic granulomas may occur at various sites. M...

Pyogenic granulomas may occur at various sites. More than 60% of all lesions develop on the head and neck.

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Pyogenic granulomas may occur at various sites. M...

Pyogenic granulomas may occur at various sites. More than 60% of all lesions develop on the head and neck.


Small pyogenic granuloma.

Small pyogenic granuloma.

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Small pyogenic granuloma.

Small pyogenic granuloma.


Pathophysiology

Although most patients (74.2%) do not have a history of trauma or predisposing dermatologic conditions, in many cases, a history of recent trauma at the site is present. Large numbers of lesions may occur following damage to diffuse areas skin by burns or other trauma.10,11 A nitric oxide synthase–dependent mechanism is thought to contribute to angiogenesis and the rapid growth of pyogenic granulomas. They are benign vascular proliferations, but the specific pathophysiology of these lesions is unknown.

Frequency

United States

Pyogenic granulomas account for 0.5% of skin lesions in infants and children and are also found in the oral mucosa in 2% of pregnant women.

Mortality/Morbidity

Most pyogenic granulomas are asymptomatic except for mild tenderness and a tendency to bleed with little or no trauma. They are benign and easily treated. Rarely, pyogenic granulomas in unusual sites such as the intestines may result in significant bleeding12,13,14 or other major complications.15

Race

No substantial difference in incidence is found between races.

Sex

One study of 178 patients younger than 17 years reported the male-to-female ratio as 3:2.16 In adults, pyogenic granulomas are more common in females because of pregnancy-related lesions.

Age

Pyogenic granulomas are most common in the first 5 years of life.17

Clinical

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.

Physical

  • Pyogenic granulomas 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 mucosa20,24 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.

Causes

  • Originally, pyogenic granulomas 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.2 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.

More on Pyogenic Granuloma

Overview: Pyogenic Granuloma
Differential Diagnoses & Workup: Pyogenic Granuloma
Treatment & Medication: Pyogenic Granuloma
Follow-up: Pyogenic Granuloma
Multimedia: Pyogenic Granuloma
References
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References

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  42. Tursen U, Demirkan F, Ikizoglu G. Giant recurrent pyogenic granuloma on the face with satellitosis responsive to systemic steroids. Clin Exp Dermatol. Jan 2004;29(1):40-1. [Medline].

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Further Reading

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Keywords

pyogenic granuloma, PG, granuloma gravidarum, granuloma telangiectaticum, lobular capillary hemangioma, pregnancy tumor, gingival lesion, exophytic circumscribed lesion, polymorphonuclear leukocytes, satellitosis, intravenous pyogenic granuloma, nevi, warts, port-wine stain, amelanotic melanoma, human papillomavirus, bacillary angiomatosis, polymorphonuclear leukocytes

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

Brett Steinberg, DO, Staff Physician, Department of Internal Medicine, Walter Reed Army Medical Center
Brett Steinberg, DO is a member of the following medical societies: American Osteopathic Association
Disclosure: Nothing to disclose.

Medical Editor

Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; 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, and American Osteopathic Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head, Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School
Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi
Disclosure: Nothing to disclose.

CME Editor

Merrily P M Poth, MD, Professor, Department of Pediatrics and Neuroscience, Uniformed Services University of the Health Sciences
Merrily P M Poth, MD is a member of the following medical societies: American Academy of Pediatrics, Endocrine Society, and Lawson-Wilkins Pediatric Endocrine Society
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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