What is pyogenic granuloma?

Pyogenic Granuloma: Clinical Features and Management

Pyogenic granuloma is a benign acquired vascular lesion of the skin and mucous membranes characterized by rapid growth, frequent bleeding, and a typically pedunculated appearance, despite its misleading name being neither pyogenic nor granulomatous in nature. 1, 2

Definition and Classification

Pyogenic granuloma, also known as lobular capillary hemangioma, is classified as a reactive proliferating vascular lesion within the broader category of vascular neoplasms according to the International Society for the Study of Vascular Anomalies classification system. 1, 3

Key distinctions:

• It is not a true hemangioma but rather a reactive vascular proliferation
• It is different from infantile hemangiomas and other vascular tumors
• It should not be confused with congenital hemangiomas (RICH or NICH)

Clinical Presentation

Pyogenic granulomas typically present with the following characteristics:

• Rapid growth pattern
• Median size of approximately 6.5 mm
• Frequently develops a pedunculated base
• Color varies from red to purplish
• Prone to bleeding that is often difficult to control when eroded 1, 4
• Most commonly located on the head and neck, particularly the cheek and intraoral regions 4
• Can affect all age groups, with approximately 12% occurring in infancy and 42% presenting during the first 5 years of life 1

Histopathological Features

The natural course of pyogenic granuloma can be categorized into three distinct phases:

1. Cellular phase: Diffuse endothelial cells with few budding into capillaries
2. Capillary/vascular phase: Further classified into:
   • Lobular capillary hemangioma (LCH): Numerous blood vessels organized into lobular aggregates
   • Non-lobular capillary hemangioma (non-LCH): Lacks organization and resembles granulation tissue
3. Involutionary phase: Characterized by extensive fibrosis in the connective tissue 5

Differential Diagnosis

Pyogenic granuloma can sometimes mimic more serious conditions:

• Pigmented melanoma (when the lesion appears dark purple or black) 6
• Squamous cell carcinoma (particularly in nail bed locations) 7
• Other vascular tumors or malformations

Management Approaches

Diagnostic Evaluation

• Clinical examination to identify the characteristic pedunculated, easily bleeding lesion
• Dermoscopic evaluation may be helpful but can sometimes be misleading 6
• Histopathological examination is essential for definitive diagnosis and to rule out malignancy 4, 7

Treatment Options

1. Surgical excision with direct closure:

   • Associated with the lowest recurrence rate
   • Provides tissue for histopathological analysis
   • Recommended for most cases 4

2. Alternative treatments:

   • Silver nitrate chemical cauterization
   • Cryotherapy (particularly for pyogenic granulomas associated with EGFR inhibitors) 1
   • Topical treatments:
     • Topical timolol 0.5% gel (twice daily under occlusion for 1 month) has shown efficacy in cases associated with EGFR inhibitors 1
     • High-potency topical corticosteroids alone or combined with topical antibiotics for smaller lesions 1

3. For periungual pyogenic granulomas:

   • Preventive measures include gentle nail care, avoiding trauma, and regular nail trimming 1
   • Surgical treatment may be necessary for intolerable or severe cases 1

Special Considerations

• Trauma history is common in the development of pyogenic granulomas 2, 7
• Lesions may eventually regress, but removal is usually sought due to bleeding, discomfort, or cosmetic concerns 4
• Recurrence is possible, though rates are generally low with proper excision 4
• All removed tissue should undergo histopathological examination to exclude malignancy 4, 7

Conclusion

Pyogenic granuloma represents a benign vascular proliferation that can be effectively managed with surgical excision in most cases. Despite its benign nature, histopathological confirmation is essential to rule out more serious conditions that may present similarly.