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: Dec 4, 2007

Introduction

Background

Pyogenic granulomas (PGs) are benign vascular lesions that occur most commonly on the acral skin of children. The term PG 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 PG as a clinically polypoid or exophytic circumscribed lesion is of importance to the clinician and pathologist because this feature distinguishes PG from most malignant vascular tumors. Although PGs 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 PG with satellitosis and intravenous PG. Satellite lesions of smaller PGs may develop at the same time as the primary lesion or may occur after attempted treatment of the primary lesion.

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. A nitric oxide synthase–dependent mechanism is thought to contribute to angiogenesis and the rapid growth of PGs. They are benign vascular proliferations, but the specific pathophysiology of these lesions is unknown.

Frequency

United States

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.

Mortality/Morbidity

Most PGs are asymptomatic except for mild tenderness and a tendency to bleed with little or no trauma. They are benign and easily treated.

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 3:2.1 In adults, PGs are more common in females because of pregnancy-related lesions.

Age

PGs are most common in the first 5 years of life.

Clinical

History

Patients 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 (PGs) may occur following minor physical trauma or burns.
  • How long has the lesion been present? Most PGs 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 PGs bleed easily. If the lesion does not bleed with light rubbing, a diagnosis of PG 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 PG.
  • Is the patient pregnant? Oral PGs 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.2
  • 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? PGs may recur. This is more likely when they are incompletely removed, but recurrence is also possible after apparently complete removal. PGs 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 PG-like lesions during isotretinoin therapy have been reported.

Physical

  • 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, PGs 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 (5.0%). Most (88.2%) occur on the skin, and the rest involve mucous membranes of the oral cavity and conjunctivae.
  • In pregnant women, PGs are most often found on the gingival mucosa but they have been known to appear in nonoral areas such as the fingers and inguinal crease.
  • PGs may occur within a port-wine stain; the presence of a vascular birthmark in the region of the PG may be significant.
  • Amelanotic melanoma may closely mimic a PG in appearance. Closely examine the skin immediately adjacent to the lesion for any pigmentary irregularity.

Causes

  • Originally, 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.
  • PGs 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 PG with satellitosis is an uncommon variant. In one patient with recurrent PG with satellitosis, Warthin-Starry staining of the lesions revealed clumps of dark bacilli as found in patients with bacillary angiomatosis.3 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 PG 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
[ CLOSE WINDOW ]

References

  1. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol. Dec 1991;8(4):267-76. [Medline].

  2. Wang PH, Chao HT, Lee WL, et al. Severe bleeding from a pregnancy tumor. A case report. J Reprod Med. Jun 1997;42(6):359-62. [Medline].

  3. Itin PH, Fluckiger R, Zbinden R, Frei R. Recurrent pyogenic granuloma with satellitosis--a localized variant of bacillary angiomatosis?. Dermatology. 1994;189(4):409-12. [Medline].

  4. Bastug DF, Ness DT, DeSantis JG. Bacillary angiomatosis mimicking pyogenic granuloma in the hand: a case report. J Hand Surg [Am]. Mar 1996;21(2):307-8. [Medline].

  5. Ceyhan M, Erdem G, Kotiloglu E, et al. Pyogenic granuloma with multiple dissemination in a burn lesion. Pediatr Dermatol. May-Jun 1997;14(3):213-5. [Medline].

  6. Dictor M, Bendsoe N, Runke S, Witte M. Major basement membrane components in Kaposi's sarcoma, angiosarcoma and benign vascular neogenesis. J Cutan Pathol. Oct 1995;22(5):435-41. [Medline].

  7. Dollery W. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Curettage or silver nitrate for pyogenic granulomas on the hand. J Accid Emerg Med. Mar 1999;16(2):140-1. [Medline].

  8. Epivatianos A, Antoniades D, Zaraboukas T, et al. Pyogenic granuloma of the oral cavity: comparative study of its clinicopathological and immunohistochemical features. Pathol Int. Jul 2005;55(7):391-7. [Medline].

  9. Fortna RR, Junkins-Hopkins JM. A case of lobular capillary hemangioma (pyogenic granuloma), localized to the subcutaneous tissue, and a review of the literature. Am J Dermatopathol. Aug 2007;29(4):408-11. [Medline].

  10. Giblin AV, Clover AJ, Athanassopoulos A, Budny PG. Pyogenic granuloma - the quest for optimum treatment: Audit of treatment of 408 cases. J Plast Reconstr Aesthet Surg. 2007;60(9):1030-5. [Medline].

  11. Gonzalez S, Vibhagool C, Falo LD Jr, et al. Treatment of pyogenic granulomas with the 585 nm pulsed dye laser. J Am Acad Dermatol. Sep 1996;35(3 Pt 1):428-31. [Medline].

  12. Hagler J, Hodak E, David M, Sandbank M. Facial pyogenic granuloma-like lesions under isotretinoin therapy. Int J Dermatol. Mar 1992;31(3):199-200. [Medline].

  13. Harrington P, O'Kelly A, Trail IA, Freemont AJ. Amelanotic subungual melanoma mimicking pyogenic granuloma in the hand. J R Coll Surg Edinb. Aug 2002;47(4):638-40. [Medline].

  14. Holbe HC, Frosch PJ, Herbst RA. Surgical pearl: ligation of the base of pyogenic granuloma--an atraumatic, simple, and cost-effective procedure. J Am Acad Dermatol. Sep 2003;49(3):509-10. [Medline].

  15. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. Dec 2006;48(4):167-75. [Medline].

  16. Kapadia SB, Heffner DK. Pitfalls in the histopathologic diagnosis of pyogenic granuloma. Eur Arch Otorhinolaryngol. 1992;249(4):195-200. [Medline].

  17. Le Meur Y, Bedane C, Clavere P, et al. A proliferative vascular tumour of the skin in a kidney-transplant recipient (recurrent pyogenic granuloma with satellitosis). Nephrol Dial Transplant. Jun 1997;12(6):1271-3. [Medline]. [Full Text].

  18. Lin RL, Janniger CK. Pyogenic granuloma. Cutis. Oct 2004;74(4):229-33. [Medline].

  19. Meffert JJ, Cagna DR, Meffert RM. Treatment of oral granulation tissue with the flashlamp pulsed dye laser. Dermatol Surg. Aug 1998;24(8):845-8. [Medline].

  20. Miller AM, Sahl WJ, Brown SA, et al. The role of human papillomavirus in the development of pyogenic granulomas. Int J Dermatol. Sep 1997;36(9):673-6. [Medline].

  21. Momeni AZ, Enshaieh S, Sodifi M, Aminjawaheri M. Multiple giant disseminated pyogenic granuloma in three patients burned by boiling milk. Int J Dermatol. Oct 1995;34(10):707-10. [Medline].

  22. Morelli JG. Use of lasers in pediatric dermatology. Dermatol Clin. Jul 1998;16(3):489-95. [Medline].

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

  24. Park YH, Houh D, Houh W. Subcutaneous and superficial granuloma pyogenicum. Int J Dermatol. Mar 1996;35(3):205-6. [Medline].

  25. Powell JL, Bailey CL, Coopland AT, et al. Nd:YAG laser excision of a giant gingival pyogenic granuloma of pregnancy. Lasers Surg Med. 1994;14(2):178-83. [Medline].

  26. Quitkin HM, Rosenwasser MP, Strauch RJ. The efficacy of silver nitrate cauterization for pyogenic granuloma of the hand. J Hand Surg [Am]. May 2003;28(3):435-8. [Medline].

  27. Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol. Dec 1997;37(6):887-919; quiz 920-2. [Medline].

  28. Saad RW, Sau P, Mulvaney MP, James WD. Intravenous pyogenic granuloma. Int J Dermatol. Feb 1993;32(2):130-2. [Medline].

  29. Shah M, Kingston TP, Cotterill JA. Eruptive pyogenic granulomas: a successfully treated patient and review of the literature. Br J Dermatol. Nov 1995;133(5):795-6. [Medline].

  30. Shimizu K, Naito S, Urata Y, et al. Inducible nitric oxide synthase is expressed in granuloma pyogenicum. Br J Dermatol. May 1998;138(5):769-73. [Medline].

  31. 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].

  32. Silverstein LH, Burton CH Jr, Garnick JJ, Singh BB. The late development of oral pyogenic granuloma as a complication of pregnancy: a case report. Compend Contin Educ Dent. Feb 1996;17(2):192-8; quiz 200. [Medline].

  33. Smulian JC, Rodis JF, Campbell WA, et al. Non-oral pyogenic granuloma in pregnancy: a report of two cases. Obstet Gynecol. Oct 1994;84(4 Pt 2):672-4. [Medline].

  34. Strohal R, Gillitzer R, Zonzits E, Stingl G. Localized vs generalized pyogenic granuloma. A clinicopathologic study. Arch Dermatol. Jun 1991;127(6):856-61. [Medline].

  35. Taira JW, Hill TL, Everett MA. Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol. Aug 1992;27(2 Pt 2):297-300. [Medline].

  36. 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]. [Full Text].

  37. 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].

  38. Whitaker SB, Bouquot JE, Alimario AE, Whitaker TJ Jr. Identification and semiquantification of estrogen and progesterone receptors in pyogenic granulomas of pregnancy. Oral Surg Oral Med Oral Pathol. Dec 1994;78(6):755-60. [Medline].

  39. Yuan K, Lin MT. The roles of vascular endothelial growth factor and angiopoietin-2 in the regression of pregnancy pyogenic granuloma. Oral Dis. May 2004;10(3):179-85. [Medline].

  40. Zaballos P, Salsench E, Puig S, Malvehy J. Dermoscopy of pyogenic granulomas. Arch Dermatol. Jun 2007;143(6):824. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

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
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.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation

Managing Editor

Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of 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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.