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4-year-old male with bleeding bump on cheek
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A 4-year-old boy presents with a 6-week history of a fast-growing, friable, red papule on his left cheek. The boy’s mother reports that a couple of weeks preceding the development of the lesion he had been bitten by a mosquito in the same area. She also states this new bump has bled several times over the last month, but it does not seem to cause the child any pain. She denies fevers or recent illness. She does report that a child in preschool “had something similar just last week.”
Physical exam reveals a healthy appearing, well-nourished young boy. He is afebrile, and there is no lymphadenopathy on exam. On his left cheek, there is a 0.6-cm bright red, shiny, discrete papule with a small collarette of scale at the base. The skin circumscribing the papule appears otherwise normal.
Figure 1. Patient presents with a 0.6-cm bright red, shiny, discrete papule with a small collarette of scale at the base on his left cheek.
Source: Krakowski AC
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Case Discussion
Answer: E. – False! Pyogenic granulomas are common benign lesions that occur more frequently in children and young adults, but they can occur at any age. The name “pyogenic granuloma” does not accurately represent these lesions because they are neither infectious nor granulomatous. Instead, the pathogenesis of these lesions is thought to be the result of reactive neovascularization.
Patients usually present with a rapidly growing bright red papule and often report a history of bleeding with minor trauma; consequently, it is not uncommon for patients to arrive to dermatology clinic wearing a bandage over the lesion (ie, the so-called “Band-Aid” sign). The average age of presentation for pyogenic granulomas in children is 6.7 years, and 42% occur by age 5 years. The most common locations are gingiva, fingers, lips, face, and tongue; however, internal lesions may occur as well and may result in gastrointestinal bleeding when present in the gastrointestinal tract.
Pyogenic granulomas can occur after history of trauma to the area. Other factors that play a role in their development include female sex hormones, with oral mucosal lesions occurring more frequently during pregnancy and in women using oral contraceptives. Up to 70% of lesions in women present on the gingiva, lips, or buccal mucosa. Other drugs that have a reported association with pyogenic granulomas include systemic retinoids (eg, isotretinoin for acne), Crixivan (indinavir, Merck), and EGFR inhibitors.
Pyogenic granulomas can generally be diagnosed clinically; however, a bleeding skin lesion can be concerning for several malignant neoplasms. Differential diagnosis includes amelanotic melanoma, Kaposi sarcoma, basal cell carcinoma, bacillary angiomatosis, hemangioma, metastatic tumors, and granulation tissue. Irritated benign nevi and warts also can clinically mimic pyogenic granulomas. Histological confirmation is, therefore, recommended when the lesion is clinically suspicious.
Multiple treatment modalities have been used to successfully treat pyogenic granulomas. Excision, shave excision, laser surgery, sclerotherapy, electrodesiccation, curettage, ligation, cryotherapy, or a combination of these methods have all been reported to effectively treat pyogenic granulomas. In children, noninvasive methods of treatment may be preferred, and recent success with the use of oral and topical nonselective beta-adrenergic antagonists such as propranolol and timolol have been reported. Shave excision (with or without curettage) followed by electrodessication of the base tends to yield cosmetically excellent results with infrequent rates of recurrence.
- References:
- Lin RL, et al. Cutis. 2004;74:229-233.
- Wine LL, et al. Pediatr Dermatol. 2014;doi:10.1111/pde.12217.
- North PE, et al. Dermatology. In: Bologna JL, et al. Dermatology. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2012:1922-1923.
- For more information:
- Laura F. Sandoval, DO, is a second-year dermatology resident at Sampson Regional Medical Center, in Clinton N.C. She can be reached at lsandovaldo10@gmail.com.
- Andrew C. Krakowski, MD, is chief medical officer of DermOne in West Conshohocken, Pa.
Disclosures: Sandoval and Krakowski report no relevant financial disclosures.