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10-year-old with bright red papule
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A 10-year-old healthy male presents to your office with a two month history of a rapidly enlarging bright red papule on his chest. Over the past few weeks, it has stabilized in size; however, he complains that it occasionally bleeds when accidentally traumatized, and the bleeding is often prolonged.
Marissa J. Perman is a second-year dermatolology resident at the University of Cincinnati.
He does not recall any prior history of injury to the site. On exam, he has a 5-mm pedunculated, firm, cherry red, smooth, focally crusted papule surrounded by a collarette of scale at the base.
What is your diagnosis?
Diagnosis: Pyogenic granuloma
Pyogenic granuloma (PG) is also known as lobular capillary hemangioma. These collections of rapidly proliferating capillaries are common, acquired, benign vascular lesions. PGs are most prevalent in children aged 1 to 5 years and in pregnant women but may develop at any age. They are not associated with infection nor are they granulomas, despite the terms "pyogenic" and "granuloma" in the name. Due to the friable nature and risk of ulceration and bleeding, they are often brought to the attention of a health professional.
The pathogenesis is unknown but thought to be a reactive neovascularization due to trauma in some cases. The increased incidence of lesions during pregnancy followed by regression postpartum as well as the association with the use of oral contraceptive pills suggests a hormonal component. Other medications have also been associated with PG and include reverse transcriptase inhibitors, indinavir, topical tretinoin, isotretinoin, and 5-fluorouracil.
Clinically, PG presents as a solitary cherry red or violaceous firm nodule that may contain an ulcerated, erosive or friable surface. PG may also be sessile, polypoid, pedunculated or multilobulated, ranging in size from a few millimeters to several centimeters.
Location of the lesions include most commonly head, neck and fingers, followed by trunk, extremities, and mucous membranes (usually oral cavity and conjuctiva). Gingival lesions are common in pregnancy. PGs can also be found in the gastrointestinal tract, nasal mucosa, larynx and cornea. Less commonly, PGs can be disseminated, subcutaneous or intravascular. Satellite recurrences following destruction have also been reported.
Most PGs are diagnosed clinically; however, some lesions may be difficult to distinguish from other vascular and non-vascular neoplasms. The most common misdiagnosis is "hemangioma," however, typical infantile hemangiomas only present in the first several weeks of life. The differential diagnosis includes Spitz nevus, acquired tufted angioma, Kaposi’s sarcoma, bacillary angiomatosis, cherry hemangioma, glomus tumor, angiokeratoma, proliferating pilomatricoma, nodular amelanotic malignant melanoma, irritated nevus or verruca (wart) and eccrine poroma. Biopsy helps distinguish these different entities.
PGs histopathologically demonstrate a well-circumscribed, often pedunculated proliferation of small capillaries arranged in lobules set in a fibromyxoid matrix and surrounded by a mild mixed infiltrate consisting of lymphocytes, plasma cells and occasional mast cells. There may be an epithelial collarette at the lateral margins.
There are several therapeutic options. Observation is reasonable if the lesion is small and asymptomatic; however, many patients request therapy due to the friable nature of the lesion and frequent episodes of bleeding. Simple office-based therapies include cryotherapy (of small lesions) or shave excision followed by electrocautery of the base under local anesthesia. Other therapies include curettage, surgical excision, pulsed dye laser, carbon dioxide laser, Nd-Yag laser, topical imiquimod 5% cream, intralesional steroids or sclerotherapy. Patients should be counseled on the risk of recurrence as well as possible scarring after treatment. Practioners should be aware of this common benign vascular neoplasm and possible therapeutic options for symptomatic lesions.
For more information:
- Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol. 1991;8(4):267-276.
- Pagliai K. Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. 2004;21(1):10-3.
- Scheinfeld NS. Pyogenic Granuloma. Skinmed. 2008;7(1):37-9.