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Pediatric Pyogenic Granuloma

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

Background

Pyogenic granulomas (PGs) are benign vascular lesions that occur most commonly on the acral skin of children.[1, 2] 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.[3]

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.[4] They are usually easily treated with surgical removal but may recur.

Uncommon variants include pyogenic granuloma with satellitosis,[5, 6, 7] intravenous pyogenic granulomas,[8] subcutaneous pyogenic granulomas,[9, 10] and eruptive pyogenic granulomas.[11, 12, 13] 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. See the images 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.
Pyogenic granulomas usually bleed with little or n 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 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.
Pyogenic granulomas may occur at various sites. Mo 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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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.[14, 15] A nitric oxide synthase–dependent mechanism is thought to contribute to angiogenesis and the rapid growth of pyogenic granulomas (PGs). They are benign vascular proliferations, but the specific pathophysiology of these lesions is unknown.

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Epidemiology

US frequency

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

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]

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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.

References
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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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