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BASICS

Description

  • Benign vascular proliferations (lobular capillary hemangiomas).
  • Commonly on head, neck, lips, oral cavity, trunk, extremities.
  • Rapidly growing erythematous to violaceous nodules; pedunculated or sessile.
  • Friable, erosive surface prone to bleeding.
  • Rare spontaneous regression.

Epidemiology

  • Peak incidence in children and young adults.
  • Common in early pregnancy.
  • Male predominance in childhood/adolescence; female predominance during reproductive years <40 years.
  • Prevalence: up to 1 in 25,000 adults intraoral PG; cutaneous PG 0.5% of childhood skin nodules.

Etiology and Pathophysiology

  • Cause unknown.
  • Aberrant capillary proliferation secondary to minor trauma.
  • Associated with peripheral nerve injury, inflammatory systemic diseases, and medications (retinoids, systemic steroids, protease inhibitors, EGFR inhibitors).
  • Hormonal influences in pregnancy.
  • Not a true neoplasm or granuloma histologically.

Risk Factors

  • Pregnancy
  • Trauma (including intraoral/surgical)
  • Inflammatory systemic diseases
  • Certain medications

General Prevention

  • Good oral hygiene may reduce risk.

DIAGNOSIS

History

  • Solitary lesion, rapid growth over days to weeks.
  • Bleeds easily.
  • Growth during pregnancy with partial postpartum regression.

Physical Exam

  • Commonly on head, neck, upper extremities; gingiva is most common oral site.
  • Bright red, friable papule or nodule.
  • Moist, sometimes scaly surface with serosanguineous crust.
  • Size <1 cm typically, may reach 2–3 cm; giant lesions rare.
  • Soft, pedunculated or sessile.
  • Dermoscopy: red homogenous area, white collarette, intersected by white lines.

Differential Diagnosis

  • Benign: Cherry/infantile hemangioma, fibrous papule, bacillary angiomatosis, carbuncle/furuncle.
  • Malignant: Basal cell carcinoma, squamous cell carcinoma, amelanotic melanoma, Kaposi sarcoma, cutaneous metastases.

Diagnostic Tests

  • No labs needed for diagnosis.
  • Excisional or shave biopsy recommended.
  • Histopathology: endothelial-lined vascular spaces, connective tissue stroma, mixed acute/chronic inflammation, no granulomas, abundant mitoses, resembling granulation tissue with immature capillaries.

TREATMENT

General Measures

  • Full-thickness surgical excision preferred for histologic confirmation and minimizing recurrence.
  • Adequate excision necessary; residual tissue causes recurrence.

Medication

  • Topical imiquimod.
  • Silver nitrate.
  • Topical timolol or propranolol.
  • Topical phenol (periungual lesions).

Surgery and Procedures

  • Shave biopsy with cautery for pedunculated lesions.
  • Punch biopsy for small lesions.
  • Electrosurgery (electrodesiccation and curettage).
  • CO2 laser ablation for superficial dermal lesions.
  • Cryotherapy (recurrence ~2%).
  • Pulsed dye or CO2 laser therapy.

ONGOING CARE

Patient Education

  • Avoid trauma post-excision.
  • Educate on benign nature and recurrence risk.

Prognosis

  • Some lesions resolve spontaneously within 6 months.
  • Recurrence rate 4–5% with treatment.

Complications

  • Recurrence with satellite lesions near original site.

Clinical Pearls

  • Benign, rapidly growing vascular tumor, often on exposed sites.
  • Excisional biopsy recommended for diagnosis and to exclude malignancy.
  • Adequate excision minimizes recurrence.
  • Laser and topical therapies are effective alternatives.

References

  1. Lin RL, Janniger CK. Pyogenic granuloma. Cutis. 2004;74(4):229-233.
  2. Borden A, Harrington JW. Pyogenic granuloma: an overview of pathogenesis, diagnosis, and management. Consultant. 2018;58(6):e181.
  3. Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. 2004;21(1):10-13.
  4. Plachouri KM, Georgiou S. Therapeutic approaches to pyogenic granuloma: an updated review. Int J Dermatol. 2019;58(6):642-648.
  5. Lee J, Sinno H, Tahiri Y, et al. Treatment options for cutaneous pyogenic granulomas: a review. J Plast Reconstr Aesthet Surg. 2011;64(9):1216-1220.