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Pediatric Pyogenic Granuloma Treatment & Management

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

Medical Care

Oral and topical beta-blocker therapy has become first-line treatment for pediatric pyogenic granuloma (PG) because of good efficacy and minimal adverse effects.[27, 28] Khorsand et al report successful treatment of a 5-month-old child with pyogenic granuloma on the cheek with topical timolol 0.5% gel for 24 weeks without recurrence.[29] Wine et al describe similar results with topical timolol 0.5-2% 2-3 times daily for 12-24 weeks, and systemic propranolol at 2 mg/kg twice daily for 6 months, or until resolution of the lesion.[27] While the exact mechanism is unknown, beta-blockers are thought to inhibit vascular endothelial growth factor (VEGF) and modulate the growth of vascular tumors, resulting in apoptosis over a long course of treatment.

New treatment options may include topical treatment with imiquimod 5% cream. It is a synthetic imidazoquinoline heterocyclic amine that enhances, through cytokine induction, both the innate and acquired immune pathways, resulting in immunomodulating, antiviral, and antitumor effects.[30, 31, 32] Definitive data on its efficacy and safety on pediatric age groups are not established, but case reports describe its use in the treatment of molluscum contagiosum, anogenital warts, hemangiomas, and, recently, pyogenic granuloma.[33] Treatment results were satisfactory with minimal scarring, and adverse effects were similar to those observed in adult patients.[34]

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Surgical Care

Treatment of pyogenic granulomas (PGs) most commonly consists of shave removal and electrocautery or surgical excision with primary closure.[35] Removal of the lesion is indicated for bleeding due to trauma, discomfort, cosmetic distress, and diagnostic biopsy. The lesion may be completely removed during biopsy.

In pediatric cases, a eutectic mixture of local anesthetics (EMLA) applied to the lesion and surrounding skin under an occlusive dressing for 1-2 hours prior to additional intralesional anesthesia may be of significant value.

For solitary lesions, a shave excision and electrocautery under local anesthesia is the treatment of choice. To provide an adequate cure rate, all vascular granulation tissue must be removed or cauterized.

For large or recurrent lesions, surgical excision with primary closure may be more effective. One study reported a 43.5% recurrence rate in 23 lesions treated by shave (intradermal) excision and cautery or cautery alone. Lesions treated by full-thickness skin excision and linear closure did not recur.

Therapy with the pulsed-dye laser at vascular-specific 585 nm is very selective, usually requires no anesthesia, and produces excellent cosmetic results.[36, 37] The pulsed-dye laser works quite well for intraoral pyogenic granulomas, as observed in pregnant women. Although treatment is feasible, treatment during pregnancy is not necessary because the lesions may recur during the pregnancy and generally resolve with delivery. Various other lasers have also been shown to be effective in treating pyogenic granulomas.[38, 39, 40, 41]

Cryotherapy or silver nitrate therapy may be effective for very small lesions and exhibited a low overall recurrence rate (1.62%). However, if nonsurgical management is undertaken, cauterization with silver nitrate should be the first-line treatment.[30, 42, 43]

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Consultations

Consider referral to a dermatologist if the diagnosis is in doubt or if the availability of adequate therapy is questionable.

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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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