Patient Presentation
A 66-year-old male presented with a chief complaint of a growth in his right ear. It had appeared suddenly and grew rapidly. He reported bleeding, but no pain. His past dermatologic history included multiple non-melanoma skin cancers and actinic keratoses.
What’s Your Diagnosis?
Diagnosis: Pyogenic Granuloma
Pyogenic Granuloma (PG), also known as lobular capillary hemangioma, was initially described in 1897 by Poncet and Dor. Using the term botryomycose humaine, the two French surgeons hypothesized that the vascular masses were analogous to “mulberry-like” lesions caused by a fungal infection seen on horses.1 The term granuloma pyogenicum was proposed by Hartzell in 19042 because the lesions often ulcerated, suppurated or bled.3,4 Although this term suggests an infectious origin with granulomatous inflammation, fungal and infectious causes have not been proven. In 1980, the term lobular capillary hemangioma was introduced to describe the histopathologic appearance of the lesion.5 The lesions have also been referred to as granuloma telangiectatium and granuloma pediculatum.2,6
Clinical Features
A common benign acquired vascular neoplasm, PG often manifests as a tumor of the skin and mucosal surfaces.5,6,7 The clinical presentation is variable. Lesions may manifest as sessile, pedunculated or dome-shaped masses with a glistening surface.2,8,9 Color ranges from bright hemorrhagic to dusky red, violaceous to brown-black. Surface may be smooth or display erosions or crusts. Lesions have a sudden onset and grow rapidly.10 Minor trauma may result in profuse, difficult-to-control bleeding.2,7,11 Bleeding is refractory to pressure.12 Children with PG frequently present to the emergency room with a blood-soaked adhesive bandage6,9 and a history of a red papule or nodule that bled easily with provocation.9,13 Often developing at sites of previous injury, PG is commonly recurrent.2,14 Although PG typically occurs as small (5 mm to 10 mm), solitary lesions,7,9 satellite lesions and large-sized lesions have been reported.7 Rarely, disseminated lesions occur on the trunk as recurrent lesions after excision.7,13 Dermoscopic exam often demonstrates a reddish homogeneous area with a white collarette in the periphery and white rail lines that intersect the lesion. The blue, brown or black pigmentation noted with the presence of melanin in the tumor is lacking with PG.2
According to a study of 325 cases by Harris et al, PG occurs with equal frequency in males and females.2 Reports describing the most common site of occurrence vary. Some report predominance along the upper extremities,15 while others describe increased incidence in the head and neck.13 Harris’s report reveals that cutaneous lesions account for 86% of cases, while mucosal lesions represent 12% of cases.2 Among cutaneous lesions, anatomical distribution from most common to least common is as follows: upper extremities, head, lower extremities, neck, and genitalia. Neck involvement was more than twice as common in men, and lower extremity presentation was twice as common in women. Harris hypothesized that this may be due to trauma secondary to shaving.2
Mucosal lesions are more predominant in females.2,6,16,17,18 The most common site of mucosal occurrence is the oral cavity, followed by nasal mucosa, conjunctiva, cervix and the vagina.
Within the pediatric population, 42% of PG cases develop during the first 5 years of life, with a male-to-female ratio of 1.5:1.14 Among adults, most cutaneous lesions arise during the second and third decades of life, while mucosal lesions peak in the fourth decade for females.2
Pyogenic granuloma can be considered a benign vascular neoplasm because PG is self-limiting and regresses when stimulus is removed.19 Even disseminated lesions resolve within several months without intervention.9,19,20,21 Most lesions are treated because they persist beyond several months and tend to cause episodic, profuse bleeding.9
Differential Diagnosis
Pyogenic granuloma is a common diagnosis. Occasionally, malignant lesions such as gingival22 or visceral metastasis have been mistaken for mucosal and cutaneous PG, respectively.23,24 Cutaneous lesions have been confused with common benign and malignant tumors including keratoachanthoma, true hemangioma, granuloma, verruca vulgaris, non-melanoma skin cancer, Spitz nevus, atypical spindle cell nevus, or Kaposi’s sarcoma.3,12,25 On dermoscopy, the absence of multiple sharply demarcated red to blue-red, round oval structures called lagoons distinguish pyogenic granuloma from angioma.2
Pathogenesis
Although the exact etiology of pyogenic granuloma is unknown, several hypotheses exist.4 Suggested etiologies include a reactive hyperproliferative immune response, trauma, hormones, bacterial and viral infections, microscopic arteriovenous anastomoses and angiogenic growth factors.4,5,26 Their strong association with previous trauma suggests these lesions are the result of a reactive, hyperplastic condition rather than a true neoplasm.2,6,4,8,27,28
The role of hormones is debatable. Cutaneous lesions exhibit a balanced sex distribution. However, mucosal lesions are increased among females of childbearing age.2 New mucosal PG, especially of the gingiva, develops in 2% of pregnancies, most often during the first trimester.29,30,31 Mucosal epithelium reportedly contains estrogen receptors. Therefore, hormones disproportionately affect mucosal epithelium compared to cutaneous epithelium.32 Moreover, estrogens appear to exaggerate the inflammatory response of gingival tissue during pregnancy.33 In this context, the lesion may be referred to as granuloma gravidarum, pregnancy urmos and pregnancy epulis.31 Supporting evidence also includes the increased responsiveness of vaginal mucosa to hormonal changes during the menstrual cycle.34
Pyogenic granuloma may be a disorder of angiogenesis. It is frequently reported within vascular lesions such as port wine stains, nevus flammeus, spider angiomas and hemangiomas.4,11,13,35,36 Infectious etiologies have been postulated due to the similar clinical and histopathologic presentations of bacillary angiomatosis and PG. However, examination of PG specimens has failed to show presence of Bartonella spp DNA and no other infectious sources have been found.37,38 Despite the plethora of working theories, many also believe these lesions simply arise de novo.11
Histology
Due to its histologic appearance, PG is commonly referred to as lobular capillary hemangioma. Active endothelial cell proliferation results in lobular capillaries separated by fibrous connective tissue.4,6,7 Each lobule contains a central feeder vessel surrounded by smaller capillaries.20 The fibrous septa intersecting the lesion contributes to the lobular pattern and may indicate an older granuloma.5,11,19,26 An epidermal collarette, a dermal mixture of inflammatory infiltrate, is often visualized and causes the slight pedunculation seen on gross inspection.5 (See Figures 1 and 2.)
Treatment
Small lesions can be treated with curettage, electrodessication, cryotherapy, vaporization with carbon dioxide, chemical cautery with silver nitrate, argon lasers and pulsed dye laser (PDL).4,7,39,30 For most adult uncomplicated lesions, shave excision or electrocautery reduces bleeding and yields favorable results.11 Exacerbating stimuli, such as oral contraceptives or isotretinoin, should be discontinued.20 Surgical excision is preferred for larger lesions (>10 mm),7 as conservative treatment witnesses recurrence rates as high as 16%.7,41,42 Recurrence after surgical removal is uncommon;9 however, patients may develop multiple satellite lesions after therapy.11
In children, surgical removal and subsequent electrocautery may result in a traumatic experience. Pulsed dye laser may be the most appropriate treatment modality in children.4,43 This laser is easy to use, treats rapidly and results in low morbidity. Although subtle scarring has been reported,11 selective destruction of superficial blood vessels results in reduced scar formation. Disadvantages to PDL include potential need for repeated treatments and decreased efficacy in larger lesions. Due to its minimal depth penetration, pyogenic granulomas that are pedunculated or elevated greater than 0.5 cm above the skin surface are less likely to respond.4
Resistant pyogenic granuloma has successfully been treated with a 14-week course of twice weekly imiquimod 5% topical application with complete resolution and satisfactory cosmetic outcome.44 Recurrent and aggressive lesions have been treated with systemic prednisolone (1 mg/kg orally).7 It is important to reassure patients that neither the presentation nor recurrence of pyogenic granuloma implies malignancy.11
Patient Presentation
A 66-year-old male presented with a chief complaint of a growth in his right ear. It had appeared suddenly and grew rapidly. He reported bleeding, but no pain. His past dermatologic history included multiple non-melanoma skin cancers and actinic keratoses.
What’s Your Diagnosis?
Diagnosis: Pyogenic Granuloma
Pyogenic Granuloma (PG), also known as lobular capillary hemangioma, was initially described in 1897 by Poncet and Dor. Using the term botryomycose humaine, the two French surgeons hypothesized that the vascular masses were analogous to “mulberry-like” lesions caused by a fungal infection seen on horses.1 The term granuloma pyogenicum was proposed by Hartzell in 19042 because the lesions often ulcerated, suppurated or bled.3,4 Although this term suggests an infectious origin with granulomatous inflammation, fungal and infectious causes have not been proven. In 1980, the term lobular capillary hemangioma was introduced to describe the histopathologic appearance of the lesion.5 The lesions have also been referred to as granuloma telangiectatium and granuloma pediculatum.2,6
Clinical Features
A common benign acquired vascular neoplasm, PG often manifests as a tumor of the skin and mucosal surfaces.5,6,7 The clinical presentation is variable. Lesions may manifest as sessile, pedunculated or dome-shaped masses with a glistening surface.2,8,9 Color ranges from bright hemorrhagic to dusky red, violaceous to brown-black. Surface may be smooth or display erosions or crusts. Lesions have a sudden onset and grow rapidly.10 Minor trauma may result in profuse, difficult-to-control bleeding.2,7,11 Bleeding is refractory to pressure.12 Children with PG frequently present to the emergency room with a blood-soaked adhesive bandage6,9 and a history of a red papule or nodule that bled easily with provocation.9,13 Often developing at sites of previous injury, PG is commonly recurrent.2,14 Although PG typically occurs as small (5 mm to 10 mm), solitary lesions,7,9 satellite lesions and large-sized lesions have been reported.7 Rarely, disseminated lesions occur on the trunk as recurrent lesions after excision.7,13 Dermoscopic exam often demonstrates a reddish homogeneous area with a white collarette in the periphery and white rail lines that intersect the lesion. The blue, brown or black pigmentation noted with the presence of melanin in the tumor is lacking with PG.2
According to a study of 325 cases by Harris et al, PG occurs with equal frequency in males and females.2 Reports describing the most common site of occurrence vary. Some report predominance along the upper extremities,15 while others describe increased incidence in the head and neck.13 Harris’s report reveals that cutaneous lesions account for 86% of cases, while mucosal lesions represent 12% of cases.2 Among cutaneous lesions, anatomical distribution from most common to least common is as follows: upper extremities, head, lower extremities, neck, and genitalia. Neck involvement was more than twice as common in men, and lower extremity presentation was twice as common in women. Harris hypothesized that this may be due to trauma secondary to shaving.2
Mucosal lesions are more predominant in females.2,6,16,17,18 The most common site of mucosal occurrence is the oral cavity, followed by nasal mucosa, conjunctiva, cervix and the vagina.
Within the pediatric population, 42% of PG cases develop during the first 5 years of life, with a male-to-female ratio of 1.5:1.14 Among adults, most cutaneous lesions arise during the second and third decades of life, while mucosal lesions peak in the fourth decade for females.2
Pyogenic granuloma can be considered a benign vascular neoplasm because PG is self-limiting and regresses when stimulus is removed.19 Even disseminated lesions resolve within several months without intervention.9,19,20,21 Most lesions are treated because they persist beyond several months and tend to cause episodic, profuse bleeding.9
Differential Diagnosis
Pyogenic granuloma is a common diagnosis. Occasionally, malignant lesions such as gingival22 or visceral metastasis have been mistaken for mucosal and cutaneous PG, respectively.23,24 Cutaneous lesions have been confused with common benign and malignant tumors including keratoachanthoma, true hemangioma, granuloma, verruca vulgaris, non-melanoma skin cancer, Spitz nevus, atypical spindle cell nevus, or Kaposi’s sarcoma.3,12,25 On dermoscopy, the absence of multiple sharply demarcated red to blue-red, round oval structures called lagoons distinguish pyogenic granuloma from angioma.2
Pathogenesis
Although the exact etiology of pyogenic granuloma is unknown, several hypotheses exist.4 Suggested etiologies include a reactive hyperproliferative immune response, trauma, hormones, bacterial and viral infections, microscopic arteriovenous anastomoses and angiogenic growth factors.4,5,26 Their strong association with previous trauma suggests these lesions are the result of a reactive, hyperplastic condition rather than a true neoplasm.2,6,4,8,27,28
The role of hormones is debatable. Cutaneous lesions exhibit a balanced sex distribution. However, mucosal lesions are increased among females of childbearing age.2 New mucosal PG, especially of the gingiva, develops in 2% of pregnancies, most often during the first trimester.29,30,31 Mucosal epithelium reportedly contains estrogen receptors. Therefore, hormones disproportionately affect mucosal epithelium compared to cutaneous epithelium.32 Moreover, estrogens appear to exaggerate the inflammatory response of gingival tissue during pregnancy.33 In this context, the lesion may be referred to as granuloma gravidarum, pregnancy urmos and pregnancy epulis.31 Supporting evidence also includes the increased responsiveness of vaginal mucosa to hormonal changes during the menstrual cycle.34
Pyogenic granuloma may be a disorder of angiogenesis. It is frequently reported within vascular lesions such as port wine stains, nevus flammeus, spider angiomas and hemangiomas.4,11,13,35,36 Infectious etiologies have been postulated due to the similar clinical and histopathologic presentations of bacillary angiomatosis and PG. However, examination of PG specimens has failed to show presence of Bartonella spp DNA and no other infectious sources have been found.37,38 Despite the plethora of working theories, many also believe these lesions simply arise de novo.11
Histology
Due to its histologic appearance, PG is commonly referred to as lobular capillary hemangioma. Active endothelial cell proliferation results in lobular capillaries separated by fibrous connective tissue.4,6,7 Each lobule contains a central feeder vessel surrounded by smaller capillaries.20 The fibrous septa intersecting the lesion contributes to the lobular pattern and may indicate an older granuloma.5,11,19,26 An epidermal collarette, a dermal mixture of inflammatory infiltrate, is often visualized and causes the slight pedunculation seen on gross inspection.5 (See Figures 1 and 2.)
Treatment
Small lesions can be treated with curettage, electrodessication, cryotherapy, vaporization with carbon dioxide, chemical cautery with silver nitrate, argon lasers and pulsed dye laser (PDL).4,7,39,30 For most adult uncomplicated lesions, shave excision or electrocautery reduces bleeding and yields favorable results.11 Exacerbating stimuli, such as oral contraceptives or isotretinoin, should be discontinued.20 Surgical excision is preferred for larger lesions (>10 mm),7 as conservative treatment witnesses recurrence rates as high as 16%.7,41,42 Recurrence after surgical removal is uncommon;9 however, patients may develop multiple satellite lesions after therapy.11
In children, surgical removal and subsequent electrocautery may result in a traumatic experience. Pulsed dye laser may be the most appropriate treatment modality in children.4,43 This laser is easy to use, treats rapidly and results in low morbidity. Although subtle scarring has been reported,11 selective destruction of superficial blood vessels results in reduced scar formation. Disadvantages to PDL include potential need for repeated treatments and decreased efficacy in larger lesions. Due to its minimal depth penetration, pyogenic granulomas that are pedunculated or elevated greater than 0.5 cm above the skin surface are less likely to respond.4
Resistant pyogenic granuloma has successfully been treated with a 14-week course of twice weekly imiquimod 5% topical application with complete resolution and satisfactory cosmetic outcome.44 Recurrent and aggressive lesions have been treated with systemic prednisolone (1 mg/kg orally).7 It is important to reassure patients that neither the presentation nor recurrence of pyogenic granuloma implies malignancy.11
Patient Presentation
A 66-year-old male presented with a chief complaint of a growth in his right ear. It had appeared suddenly and grew rapidly. He reported bleeding, but no pain. His past dermatologic history included multiple non-melanoma skin cancers and actinic keratoses.
What’s Your Diagnosis?
Diagnosis: Pyogenic Granuloma
Pyogenic Granuloma (PG), also known as lobular capillary hemangioma, was initially described in 1897 by Poncet and Dor. Using the term botryomycose humaine, the two French surgeons hypothesized that the vascular masses were analogous to “mulberry-like” lesions caused by a fungal infection seen on horses.1 The term granuloma pyogenicum was proposed by Hartzell in 19042 because the lesions often ulcerated, suppurated or bled.3,4 Although this term suggests an infectious origin with granulomatous inflammation, fungal and infectious causes have not been proven. In 1980, the term lobular capillary hemangioma was introduced to describe the histopathologic appearance of the lesion.5 The lesions have also been referred to as granuloma telangiectatium and granuloma pediculatum.2,6
Clinical Features
A common benign acquired vascular neoplasm, PG often manifests as a tumor of the skin and mucosal surfaces.5,6,7 The clinical presentation is variable. Lesions may manifest as sessile, pedunculated or dome-shaped masses with a glistening surface.2,8,9 Color ranges from bright hemorrhagic to dusky red, violaceous to brown-black. Surface may be smooth or display erosions or crusts. Lesions have a sudden onset and grow rapidly.10 Minor trauma may result in profuse, difficult-to-control bleeding.2,7,11 Bleeding is refractory to pressure.12 Children with PG frequently present to the emergency room with a blood-soaked adhesive bandage6,9 and a history of a red papule or nodule that bled easily with provocation.9,13 Often developing at sites of previous injury, PG is commonly recurrent.2,14 Although PG typically occurs as small (5 mm to 10 mm), solitary lesions,7,9 satellite lesions and large-sized lesions have been reported.7 Rarely, disseminated lesions occur on the trunk as recurrent lesions after excision.7,13 Dermoscopic exam often demonstrates a reddish homogeneous area with a white collarette in the periphery and white rail lines that intersect the lesion. The blue, brown or black pigmentation noted with the presence of melanin in the tumor is lacking with PG.2
According to a study of 325 cases by Harris et al, PG occurs with equal frequency in males and females.2 Reports describing the most common site of occurrence vary. Some report predominance along the upper extremities,15 while others describe increased incidence in the head and neck.13 Harris’s report reveals that cutaneous lesions account for 86% of cases, while mucosal lesions represent 12% of cases.2 Among cutaneous lesions, anatomical distribution from most common to least common is as follows: upper extremities, head, lower extremities, neck, and genitalia. Neck involvement was more than twice as common in men, and lower extremity presentation was twice as common in women. Harris hypothesized that this may be due to trauma secondary to shaving.2
Mucosal lesions are more predominant in females.2,6,16,17,18 The most common site of mucosal occurrence is the oral cavity, followed by nasal mucosa, conjunctiva, cervix and the vagina.
Within the pediatric population, 42% of PG cases develop during the first 5 years of life, with a male-to-female ratio of 1.5:1.14 Among adults, most cutaneous lesions arise during the second and third decades of life, while mucosal lesions peak in the fourth decade for females.2
Pyogenic granuloma can be considered a benign vascular neoplasm because PG is self-limiting and regresses when stimulus is removed.19 Even disseminated lesions resolve within several months without intervention.9,19,20,21 Most lesions are treated because they persist beyond several months and tend to cause episodic, profuse bleeding.9
Differential Diagnosis
Pyogenic granuloma is a common diagnosis. Occasionally, malignant lesions such as gingival22 or visceral metastasis have been mistaken for mucosal and cutaneous PG, respectively.23,24 Cutaneous lesions have been confused with common benign and malignant tumors including keratoachanthoma, true hemangioma, granuloma, verruca vulgaris, non-melanoma skin cancer, Spitz nevus, atypical spindle cell nevus, or Kaposi’s sarcoma.3,12,25 On dermoscopy, the absence of multiple sharply demarcated red to blue-red, round oval structures called lagoons distinguish pyogenic granuloma from angioma.2
Pathogenesis
Although the exact etiology of pyogenic granuloma is unknown, several hypotheses exist.4 Suggested etiologies include a reactive hyperproliferative immune response, trauma, hormones, bacterial and viral infections, microscopic arteriovenous anastomoses and angiogenic growth factors.4,5,26 Their strong association with previous trauma suggests these lesions are the result of a reactive, hyperplastic condition rather than a true neoplasm.2,6,4,8,27,28
The role of hormones is debatable. Cutaneous lesions exhibit a balanced sex distribution. However, mucosal lesions are increased among females of childbearing age.2 New mucosal PG, especially of the gingiva, develops in 2% of pregnancies, most often during the first trimester.29,30,31 Mucosal epithelium reportedly contains estrogen receptors. Therefore, hormones disproportionately affect mucosal epithelium compared to cutaneous epithelium.32 Moreover, estrogens appear to exaggerate the inflammatory response of gingival tissue during pregnancy.33 In this context, the lesion may be referred to as granuloma gravidarum, pregnancy urmos and pregnancy epulis.31 Supporting evidence also includes the increased responsiveness of vaginal mucosa to hormonal changes during the menstrual cycle.34
Pyogenic granuloma may be a disorder of angiogenesis. It is frequently reported within vascular lesions such as port wine stains, nevus flammeus, spider angiomas and hemangiomas.4,11,13,35,36 Infectious etiologies have been postulated due to the similar clinical and histopathologic presentations of bacillary angiomatosis and PG. However, examination of PG specimens has failed to show presence of Bartonella spp DNA and no other infectious sources have been found.37,38 Despite the plethora of working theories, many also believe these lesions simply arise de novo.11
Histology
Due to its histologic appearance, PG is commonly referred to as lobular capillary hemangioma. Active endothelial cell proliferation results in lobular capillaries separated by fibrous connective tissue.4,6,7 Each lobule contains a central feeder vessel surrounded by smaller capillaries.20 The fibrous septa intersecting the lesion contributes to the lobular pattern and may indicate an older granuloma.5,11,19,26 An epidermal collarette, a dermal mixture of inflammatory infiltrate, is often visualized and causes the slight pedunculation seen on gross inspection.5 (See Figures 1 and 2.)
Treatment
Small lesions can be treated with curettage, electrodessication, cryotherapy, vaporization with carbon dioxide, chemical cautery with silver nitrate, argon lasers and pulsed dye laser (PDL).4,7,39,30 For most adult uncomplicated lesions, shave excision or electrocautery reduces bleeding and yields favorable results.11 Exacerbating stimuli, such as oral contraceptives or isotretinoin, should be discontinued.20 Surgical excision is preferred for larger lesions (>10 mm),7 as conservative treatment witnesses recurrence rates as high as 16%.7,41,42 Recurrence after surgical removal is uncommon;9 however, patients may develop multiple satellite lesions after therapy.11
In children, surgical removal and subsequent electrocautery may result in a traumatic experience. Pulsed dye laser may be the most appropriate treatment modality in children.4,43 This laser is easy to use, treats rapidly and results in low morbidity. Although subtle scarring has been reported,11 selective destruction of superficial blood vessels results in reduced scar formation. Disadvantages to PDL include potential need for repeated treatments and decreased efficacy in larger lesions. Due to its minimal depth penetration, pyogenic granulomas that are pedunculated or elevated greater than 0.5 cm above the skin surface are less likely to respond.4
Resistant pyogenic granuloma has successfully been treated with a 14-week course of twice weekly imiquimod 5% topical application with complete resolution and satisfactory cosmetic outcome.44 Recurrent and aggressive lesions have been treated with systemic prednisolone (1 mg/kg orally).7 It is important to reassure patients that neither the presentation nor recurrence of pyogenic granuloma implies malignancy.11
