What is the treatment for over granulation (excessive granulation tissue)?

Treatment of Excessive Granulation Tissue

The treatment of excessive granulation tissue should include daily cleaning with antimicrobial cleanser, application of topical treatments such as silver nitrate cauterization for direct application to the overgranulation tissue, or alternatively, topical corticosteroid cream for 7-10 days with a foam dressing to provide compression. 1

Understanding Overgranulation

Excessive granulation tissue (overgranulation) is a common complication, particularly around devices such as gastrostomy tubes. It has these characteristics:

• Vascular tissue that bleeds easily and can be painful
• Appears raised above the surrounding skin with a shiny appearance
• Can impair wound healing and predispose to infection

Common Causes

• Excess moisture around the wound
• Excess friction or movement (especially from poorly secured tubes)
• Critical colonization or infection
• Leakage around tubes or devices

Treatment Algorithm

First-Line Approaches:

1. Daily Cleaning:

   • Clean the affected area at least once daily with antimicrobial cleanser 1
   • Ensure proper drying after cleaning

2. Skin Protection:

   • Apply barrier film or cream to protect surrounding skin
   • Use foam dressings rather than gauze to reduce skin irritation (foam lifts drainage away from skin) 1

3. Chemical Cautery:

   • Apply silver nitrate directly onto the overgranulation tissue 1
   • Should be applied weekly by healthcare professionals only 1
   • Note: Silver nitrate is caustic and irritating to skin and mucous membranes; handle carefully as it stains skin and clothing 2

4. Topical Corticosteroid Therapy:

   • Apply topical corticosteroid cream or ointment for 7-10 days 1
   • Use in combination with a foam dressing to provide compression to the treatment site
   • Recent evidence suggests that 1% hydrocortisone may be more effective than silver nitrate for wound healing 3

Additional Interventions:

• Apply topical antimicrobial agent under fixation devices 1
• Use foam or silver dressing over the affected area, changing only when significant exudate is present (at least weekly) 1
• For wounds with both hypergranulation and infection, consider a combination approach such as a 50/50 mixture of triamcinolone and antibiotic ointment 4

Addressing Underlying Causes

To prevent recurrence, address the factors contributing to overgranulation:

• Ensure proper tube stabilization to minimize movement and friction 1
• Verify proper tension between bolsters for gastrostomy tubes 1
• Treat any associated infection with appropriate antimicrobial therapy 1
• Manage excessive moisture around the wound site 1

Treatment Selection Based on Severity

For Mild Overgranulation:

• Daily cleaning and barrier protection may be sufficient
• Monitor for progression

For Moderate to Severe Overgranulation:

• Proceed with chemical cautery using silver nitrate or topical corticosteroid therapy
• Consider surgical removal for refractory cases 1
• Argon plasma coagulation has been described as an alternative for resistant cases 1

Special Considerations

• If treating overgranulation around gastrostomy tubes and initial treatments fail, consider trying an alternative brand or type of tube 1
• For persistent cases around tubes, removing the tube for 24-48 hours may allow slight closure of the tract, potentially resolving the issue 1
• Recent evidence suggests that topical steroids may lead to faster healing compared to silver nitrate cautery, with median reductions in wound size of 14-15mm versus 0-5mm after one month of treatment 3

Monitoring and Follow-up

• Regularly assess the overgranulation tissue for response to treatment
• If no improvement is seen with initial therapy, consider referral to a specialist for further assessment and treatment 1
• For persistent cases, evaluate for underlying factors such as foreign bodies or chronic infection