Treatment for Reactive Pseudoepitheliomatous Hyperplasia
The treatment of reactive pseudoepitheliomatous hyperplasia (PEH) is complete surgical excision of the lesion combined with treatment of the underlying causative condition—no other therapy is required for this benign reactive process. 1
Primary Treatment Approach
Surgical excision is the definitive treatment for PEH. The key principle is that PEH is a reactive epithelial proliferation, not a malignancy, and resolves once the underlying trigger is removed 1, 2. The treatment algorithm follows this sequence:
Step 1: Identify and Treat the Underlying Cause
Infectious causes: Obtain bacterial cultures from the lesion and initiate appropriate antibiotic therapy based on sensitivities 2
- In documented cases, vancomycin has been effective for resistant organisms cultured from PEH lesions 2
- Continue antibiotics until infection is cleared
Inflammatory/traumatic causes: Address the source of chronic irritation or injury 1, 2
- Remove foreign bodies if present
- Eliminate sources of chronic trauma or irritation
Associated neoplasms: If PEH is secondary to an underlying tumor (such as melanoma), treat the primary malignancy appropriately 3, 4
Step 2: Complete Surgical Excision
Perform radical excision of the PEH lesion with adequate margins 2. This is essential because:
- Conservative local excision is sufficient for isolated PEH 1
- Complete removal prevents recurrence 2
- Incomplete excision may lead to diagnostic confusion on repeat biopsy 1
Step 3: Post-Excision Wound Management
- Daily wound dressing changes with appropriate antimicrobial agents (such as vancomycin) if infection was present 2
- Monitor for complete healing and resolution
- No additional systemic therapy is required once the lesion is excised 1
Critical Clinical Pitfalls to Avoid
Do not treat PEH as squamous cell carcinoma. The most important diagnostic challenge is distinguishing PEH from well-differentiated squamous cell carcinoma 5, 1. Key differentiating factors:
- PEH shows reactive epithelial proliferation without true malignant features 1
- Small biopsy samples, incomplete excision, and dense inflammation can make this distinction difficult 1
- When in doubt, obtain adequate tissue samples with proper orientation for pathologic examination 1
Do not perform overly aggressive surgery for isolated PEH. While one case report describes total laryngectomy for laryngeal PEH with complications 5, this represents an extreme scenario with secondary complications (bleeding, abscesses, dyspnea) rather than standard management. Most PEH requires only local conservative excision 1.
Special Circumstances
PEH Associated with Malignancy
When PEH occurs overlying melanoma or other neoplasms 3, 4:
- The PEH itself requires no specific treatment beyond excision of the underlying malignancy
- Ensure adequate tissue sampling to avoid missing the underlying malignant process 4
- The presence of PEH does not alter the prognosis or treatment of the underlying malignancy 4
Recurrent or Persistent PEH
If PEH recurs after initial treatment 2:
- Re-evaluate for persistent underlying cause (ongoing infection, retained foreign body, unrecognized malignancy)
- Obtain repeat cultures and adjust antibiotic therapy accordingly 2
- Consider wider excision if initial margins were inadequate 2
Prognosis
PEH has no malignant potential and does not transform into squamous cell carcinoma 1. Complete resolution is expected with appropriate treatment of the underlying cause and adequate excision 1, 2. The combined approach of surgical excision and treatment of causative factors (particularly infection with effective antibiotics) achieves cure 2.