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. [22, 23, 24, 25, 26, 27]
-
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 Examination
Pyogenic granulomas (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, 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 mucosa [24, 28] 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.
Complications
Complications for pyogenic granulomas (PGs) may include the following:
-
Significant secondary infection (extremely uncommon)
-
Recurrence at the original site
-
Recurrence as multiple satellite lesions in the area immediately surrounding the original lesion
-
Superficial scar formation
An oral pyogenic granulomas can develop during or just after the first trimester of pregnancy. Usually, an oral pyogenic granulomas is an early slow-growing mass that, upon excision, does not leave a large defect in the periodontium that requires surgical repair. Rarely, a rapidly growing large tumor may produce significant hemorrhage.
-
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.
