Medical Care
Topical beta-blocker therapy remains a first-line treatment for pediatric pyogenic granuloma (PG) because of good efficacy and minimal adverse effects. [31, 32] Previous successful treatments have been topical timolol over 12-24 weeks; [31, 33] since then, case reports have suggested that the course may be shortened, with one case series showing resolution of ocular pyogenic granulomas over 21 days with no recurrence for at least 3 months [34] and another case report showing near-complete resolution at the scalp over 28 days. [35] Meanwhile, a prospective study of 22 children showed treatment with topical propranolol 1% ointment resulted in complete resolution in 13 children (59%) at a mean of 66 days [36] ; upon follow-up 2 years after resolution, there was no recurrence of the 13 pyogenic granulomas cured. 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.
Although not yet approved by the US Food and Drug Administration for pediatric pyogenic granulomas, possible upcoming treatments include ingenol mebutate 0.015% cream and topical imiquimod 5% cream. Ingenol mebutate is a cytoxic agent derived from the Euphorbia plant that has been successfully used in the treatment in actinic keratoses. [37] One case from 2017 reported complete resolution after 6 days of once-daily application; there was no evidence of recurrence at 5 months of follow-up. [38] Imiquimod 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. [39, 40, 41] 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, more recently, pyogenic granuloma. [41] Treatment results were satisfactory with minimal scarring, and adverse effects were similar to those observed in adult patients. [42]
Surgical Care
Nonmedical treatment of pyogenic granulomas (PGs) most commonly consists of shave removal and electrocautery or surgical excision with primary closure. [43] 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.
Various lasers serve as alternative options to surgery and have been shown to be effective in treating pyogenic granulomas. Therapy with a diode laser at wavelengths of 808-980 nm has been increasingly preferred, owing to providing a relatively bloodless surgical field while resulting in minimal swelling and scarring. [18, 44, 45] Other modalities include carbon dioxide and element-based lasers. [19, 20]
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. [21, 39, 46]
Consultations
Consider referral to a dermatologist if the diagnosis is in doubt or if the availability of adequate therapy is questionable.
Long-Term Monitoring
Following removal of the pyogenic granuloma (PG), routine wound care is the only treatment required. Follow-up visits are required only if the lesion recurs. If the lesion recurs and histopathology confirms the diagnosis, the recurrent lesion may be treated with any of the modalities previously discussed, including simply repeating the initial therapy.
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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.
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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.
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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.
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Pyogenic granulomas may be pedunculated and quite large. An area of necrosis is also common.
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Pyogenic granulomas may occur at various sites. More than 60% of all lesions develop on the head and neck.
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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.
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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.
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Small pyogenic granuloma.
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Histologic image showing epidermal erosion and crusting, thinned epidermis, vascular proliferation, and mixed inflammation with lymphocytes, histiocytes, and neutrophils. Courtesy of Medscape Dermatology.
