Medical Care

Granuloma annulare

Granuloma annulare rarely requires any treatment since spontaneous resolution is common.

Medical and surgical interventions should be avoided unless absolutely necessary.

Although there are numerous case reports of successful treatment of granuloma annulare, including medical and phototherapy options, randomized, controlled clinical trials are needed.^[9]

Pyogenic granuloma

Patients with pyogenic granuloma may present with acute bleeding from the vascular lesions, particularly when they are intraoral. For patients who present with hemorrhage, bleeding often may be controlled with direct pressure and the airway should be secured if necessary. Intravenous access may be indicated if hemorrhage is severe..

A vasoconstrictor packing (eg, cocaine or tetracaine with adrenaline) sometimes may be needed.

When bleeding is refractory or recurrent, sclerotherapy by direct injection of 1-2 mL of 1% sodium tetradecyl sulfate into the vascular plexus is usually effective and may even provide a definitive cure.

Compress the lesion for 15 minutes following injection. Sclerotherapy usually is necessary in order to allow time for the tumor vessels to go into spasm.

Effective treatment includes excision (although this may be difficult if the lesion is extensive), electrodesiccation, curettage, chemical cauterization, and injection sclerotherapy. Carbon dioxide and argon lasers have been used successfully for superficial cases of pyogenic granuloma. Pulsed-dye laser also has been shown effective in the treatment of pyogenic granulomas when the lesion is superficial and of less than 0.5 cm thickness. Advantages of excision and electrocautery are ease of use and lack of recurrences according to one recent study in children.

A meta-analysis demonstrates that surgical excision offers the lowest overall recurrence rates (2.94%) and cryotherapy offered the lowest overall recurrence rate (1.62%).^[10]If surgical excision and closure are not performed, cauterization with silver nitrate should be the first-line treatment.

In pediatrics, a case series has demonstrated the use of oral or topical beta-blockers to be a potential noninvasive treatment of mucosal pyogenic granulomas.^[11]

Consultations

If diagnosis is unproven, follow-up care with a dermatologist is indicated.

Long-Term Monitoring

Further outpatient care is needed to follow the progress of lesions because as many as 20% of children with granuloma annulare experience recurrence.

Local recurrence after treatment of pyogenic granuloma by any method is not uncommon. In a one series, most of patients with uncomplicated pyogenic granuloma were treated with single shave excision and electrocautery, with no recurrences.^[12]

Medication

Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012 Jan. 16(1):79-82. [QxMD MEDLINE Link]. [Full Text].
Spicuzza L, Salafia S, Capizzi A, Vitaliti G, Rotolo N, Leonardi S, et al. Granuloma annulare as first clinical manifestation of diabetes mellitus in children: a case report. Diabetes Res Clin Pract. 2012 Mar. 95(3):e55-7. [QxMD MEDLINE Link].
Ziemer M, Grabner T, Eisendle K, Baltaci M, Zelger B. Granuloma annulare - a manifestation of infection with Borrelia?. J Cutan Pathol. 2008 Jun 18. [QxMD MEDLINE Link].
Scott PL, Motaparthi K, Krishnan B, Hsu S. Pyogenic granuloma-like Kaposi sarcoma: a diagnostic pitfall. Dermatol Online J. 2012 Mar 15. 18(3):4. [QxMD MEDLINE Link].
Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. 1996 Jul. 41(7):467-70. [QxMD MEDLINE Link].
Krishnapillai R, Punnoose K, Angadi PV, Koneru A. Oral pyogenic granuloma-a review of 215 cases in a South Indian Teaching Hospital, Karnataka, over a period of 20 years. Oral Maxillofac Surg. 2012 Jan 26. [QxMD MEDLINE Link].
Charollais R, Aubin F, Roche-Kubler B, Puzenat E. [Two cases of granuloma annulare under anti-PD1 therapy]. Ann Dermatol Venereol. 2018 Feb. 145 (2):116-119. [QxMD MEDLINE Link].
Moshe M, Levi A, Ad-El D, Ben-Amitai D, Mimouni D, Didkovsky E, et al. Malignant melanoma clinically mimicking pyogenic granuloma: comparison of clinical evaluation and histopathology. Melanoma Res. 2018 Aug. 28 (4):363-367. [QxMD MEDLINE Link].
Thornsberry LA, English JC 3rd. Etiology, diagnosis, and therapeutic management of granuloma annulare: an update. Am J Clin Dermatol. 2013 Aug. 14(4):279-90. [QxMD MEDLINE Link].
Lee J, Sinno H, Tahiri Y, Gilardino MS. Treatment options for cutaneous pyogenic granulomas: a review. J Plast Reconstr Aesthet Surg. 2011 Sep. 64(9):1216-20. [QxMD MEDLINE Link].
Wine Lee L, Goff KL, Lam JM, Low DW, Yan AC, Castelo-Soccio L. Treatment of pediatric pyogenic granulomas using β-adrenergic receptor antagonists. Pediatr Dermatol. 2014 Mar-Apr. 31 (2):203-7. [QxMD MEDLINE Link].
Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. 2004 Jan-Feb. 21(1):10-3. [QxMD MEDLINE Link].
Looney M, Smith KM. Isotretinoin in the treatment of granuloma annulare. Ann Pharmacother. 2004 Mar. 38(3):494-7. [QxMD MEDLINE Link].
Weber HO, Borelli C, Rocken M, Schaller M. Treatment of disseminated granuloma annulare with low-dose fumaric acid. Acta Derm Venereol. 2009. 89(3):295-8. [QxMD MEDLINE Link].
Werchau S, Enk A, Hartmann M. Generalized interstitial granuloma annulare--response to adalimumab. Int J Dermatol. 2010 Apr. 49(4):457-60. [QxMD MEDLINE Link].

Media Gallery

Granuloma annulare. Courtesy of Wikimedia Commons (Mierlo at English Wikipedia).
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.