Pyogenic Granuloma
Pyogenic granulomas are common benign skin tumors.
They frequently occur after trauma and can be induced by certain classes of
medications. They are also seen in increased frequency during pregnancy.
Pyogenic granu- lomas are vascular tumors or proliferations of vascular tissue.
They occur in all races, and there is no age or gender predilection, although
they are more commonly seen in pregnancy.
Clinical Findings: Patients often present with a bleeding papule or
nodule that is beefy red and has a collarette of scale. Pyogenic granulomas are
friable and bleed easily when manipulated. There is often a preceding history
of trauma. The lesions are usually small (5 mm) papules, but some have been
reported to be 1 to 2 cm in diameter. These benign growths can also occur on
the mucosa, and another common but unique location is in a periungual position.
They can be tender and occasionally can become superinfected. A characteristic
finding is the “band-aid” sign. This sign represents the surrounding skin
findings of a contact dermatitis caused by the frequent use of bandages to
cover the pyogenic granuloma due to its propensity to bleed, sometimes
profusely. Pyogenic granulomas are more common during pregnancy and can be seen
on the gingival mucosa. The most frequent oral location of involvement is the
gingival mucosa. They rarely resolve spontaneously. The differential diagnosis
is usually between pyogenic granuloma and other vascularappearing tumors
including metastatic carcinoma, particularly renal cell carcinoma, bacillary
angiomatosis, and amelanotic melanoma. Pyogenic granulomas are almost always
removed and the diagnosis is confirmed by histopathologic evaluation.
Pathogenesis: Pyogenic granulomas are thought to arise after
trauma or secondary to medications and to be caused by a hyperplastic
proliferation of vascular tissue. Chronic localized trauma can cause the
release of vascular growth factors that may induce the proliferation. Pyogenic
granulomas have not been shown to have any genetic inheritance pattern and are
considered to be sporadic. The exact mechanism of formation is not well
understood. The fact that they are more commonly seen in pregnancy suggests
that certain hormonal regulations play a role in the formation of these tumors.
Histology: Pyogenic granulomas are also known as lobular
capillary hemangiomas. This is an excellent descriptive name. The lesion is an
exophytic growth that has a lobular configuration to its growth pattern. The
tumor is typically well circumscribed and surrounded by a collarette of
hyperplastic epithelium. Multiple capillary loops are found within each of the
tumor lobules. Strands of fibrous tissue divide the tumor into individual
lobules of varying size. Many of these lesions show evidence of surface
ulceration result- ing from thinning of the overlying epidermis. The cells
involved are bland appearing.
Treatment: Most pyogenic granulomas resolve after shave
removal and curettage with cautery of the base of the lesion. These tumors do
have a propensity to recur, and occasionally an elliptical excision is required
for removal. Application of silver nitrate and laser ablation with the pulsed
dye laser have been used successfully. If the pyogenic granulomas are drug
induced, stopping the offending medication is sometimes effective in resolving
them. However, many cases of medicationinduced pyogenic granulomas require some
method of surgical removal.
