PYOGENIC GRANULOMA

Signs and Symptoms

Pyogenic granulomas typically present as solitary, rapidly evolving papules or nodules on the skin of the face or lips, or the mucosal surfaces of the eyes or mouth.1 Other areas of the body may be affected as well.1-3 The lesions are soft in texture, usually smooth-surfaced, red to purple in coloration and may be pedunculated (i.e., stalked) in some instances.4

Patients may report various levels of discomfort, as well as a tendency for bleeding to occur with even the slightest manipulation.5,6 Often, the primary reason for presentation is a cosmetic concern.5 Patients with pyogenic granuloma may be of any age, but children and young adults appear to be affected more frequently.4,7 Similarly, there is no gender predilection overall, but pyogenic granulomas of the oral cavity do seem to be more common in women; in addition, there is a higher incidence of these lesions during pregnancy.1,8

Ocular pyogenic granuloma may be seen to affect the adnexa, the eyelids and the bulbar or palpebral conjunctiva. In rare instances, the cornea may be impacted, though involvement seems to be limited to those layers anterior to Bowman’s membrane, sparing the stroma.9,10 A number of cases have been found to occur in conjunction with punctal occlusion therapy, usually (but not always) involving intracanalicular plugs.11,12

Common ocular complaints associated with pyogenic granuloma may include tearing, foreign body sensation or interrupted eyelid closure depending upon the location of the growth. Visual acuity is only affected if the lesion interrupts the visual axis or induces a keratopathy secondary to incomplete tear film spreading.

Pathophysiology

The term “pyogenic granuloma” is a classic misnomer: these lesions are neither pyogenic (i.e., pus-producing) nor granulomatous (i.e., consisting of fibroblasts and macrophages surrounded by lymphocytes).4,5,7,13 In fact, pyogenic granulomas actually represent poly-poidal vascular proliferations, and are sometimes referred to in the literature as lobular capillary hemangiomas.13-15 In addition to capillary proliferation, the lesions are accompanied by inflammatory cells in a myxoid stroma.13 Although the precise etiology of pyogenic granuloma is undetermined, these lesions often appear to follow episodes of trauma, surgery or chronic irritation.13-15 Hormonal influences, microorganisms (e.g., Staphylococci, Bartonella, viral particles), arteriovenous malformations and cytogenetic abnormalities have also been implicated.1,5,15-18

Management

The initial step in the appropriate management of pyogenic granuloma involves ruling out other tumors and mass lesions. When the eyelids are involved, one must consider such entities as chalazia, internal hordeola, squamous cell carcinoma and sebaceous cell carcinoma in the differential. Once a definitive diagnosis has been made, a conservative attempt to regress tissue proliferation can be attempted by removing the inciting factor and prescribing topical corticosteroid preparations.12 Should these measures fail, or if the lesion is of substantial size and is compromising function of the involved tissues, medical and/or surgical intervention is warranted.

Surgical options may include such techniques as excision, curettage, shave and cautery, or combinations thereof.1,19 Other techniques that have been used successfully—whether alone or adjunctively to surgical intervention—include cryotherapy, electrodessication, cauterization with silver nitrate, microembolization, sclerotherapy (i.e., the injection of a vascular sclerosing agent into the lesion, such as tetradecyl sulfate), imiquimod cream and laser therapy.19-25 Various forms of laser have been employed in treating these lesions, including CO2 laser, Nd:YAG laser, pulsed dye laser and even diode laser.14,26-28 Laser therapy offers excellent tolerability, few adverse effects and low recurrence rates.

Despite the many options, surgery remains the preferred technique for most pyogenic granulomas today. A meta-analysis of interventional studies dating from 1956 to 2009 concluded that surgical excision offers on average the lowest rates of recurrence, the least number of treatment sessions, and the best opportunity to retain the lesion in its entirety for pathologic examination.14 Those lesions that do not lend themselves to surgery because of size, number, location or disposition of the patient may be treated by other means; of the remaining modalities, cryotherapy with liquid nitrogen carries the lowest overall recurrence rate.14

Clinical Pearls

Pyogenic granulomas are considered to be among the most common acquired vascular growths of the eyelids.29

Pyogenic granulomas have also been reported to arise within congenital capillary malformations such as port-wine stain; however, in these cases they usually present following cosmetic laser treatments.30

Pyogenic granuloma development associated with punctal plugs are believed to be related to poorly fitted or poorly designed implants that create undue irritation.12,13

Pyogenic granulomas are not malignant, and have virtually no propensity for malignant conversion; however, they must always be differentiated from malignant lesions that may present with a similar appearance.6,16

1. Giblin AV, Clover AJ, Athanassopoulos Am et al. Pyogenic granuloma – the quest for optimum treatment: Audit of treatment of 408 cases. J Plast Reconstr Aesthet Surg. 2007;60(9):1030-5.

2.Carmen González-Vela M, Fernando Val-Bernal J, Francisca Garijo M, et al. Pyogenic granuloma of the sigmoid colon. Ann Diagn Pathol. 2005;9(2):106-9.

3. Spinelli C, Di Giacomo M, Bertocchini A, et al. Multiple pyogenic granuloma of the penis in a four-year-old child: a case report. Cases J. 2009;2:7831.

4. Ting PT, Barankin B. Dermacase. Pyogenic granuloma. Can Fam Physician. 2006;52:35-6.

5. Ehmann DS, Schweitzer K, Sharma S. Ophthaproblem. Can you identify this condition? Pyogenic granuloma. Can Fam Physician. 2010;56(6):553, 556.

6. Scheinfeld NS. Pyogenic granuloma. Skinmed. 2008;7(1):37-9.

7. Murthy SC, Nagaraj A. Pyogenic granuloma. Indian Pediatr. 2012;49(10):855.

8. Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. 2004;21(1):10-3.

9. Karatza EC, Calhoun JH, Eagle RC Jr. Pyogenic granuloma of the cornea in an infant with unilateral microphthalmia. Arch Ophthalmol. 2003;121(8):1197-200.

10. Mietz H, Arnold G, Kirchhof B, et al. Pyogenic granuloma of the cornea: report of a case and review of the literature. Graefes Arch Clin Exp Ophthalmol. 1996; 234(2):131-6.

11. Chou TY, Perry HD, Donnenfeld ED et al. Pyogenic granuloma formation following placement of the Medennium SmartPLUG punctum plug. Cornea. 2006;25(4):493-5.

12. Kim BM, Osmanovic SS, Edward DP. Pyogenic granulomas after silicone punctal plugs: a clinical and histopathologic study. Am J Ophthalmol. 2005;139(4):678-84.

13. Yazici B, Ayvaz AT, Aker S. Pyogenic granuloma of the lacrimal sac. Int Ophthalmol. 2009;29(1):57-60.

14. Lee J, Sinno H, Tahiri Y, Gilardino MS. Treatment options for cutaneous pyogenic granulomas: a review. J Plast Reconstr Aesthet Surg. 2011;64(9):1216-20.

15. Demir Y, Demir S, Aktepe F. Cutaneous lobular capillary hemangioma induced by pregnancy. J Cutan Pathol. 2004;31(1):77-80.

16. Kamal R, Dahiya P, Puri A. Oral pyogenic granuloma: Various concepts of etiopathogenesis. J Oral Maxillofac Pathol. 2012;16(1):79-82.

17. da Silva AD, Silva CA, de Camargo Moraes P, et al. Recurrent oral pyogenic granuloma in port-wine stain. J Craniofac Surg. 2011;22(6):2356-8.

18. Hung CH, Kuo HW, Chiu YK, Huang PH. Intravascular pyogenic granuloma arising in an acquired arteriovenous malformation: report of a case and review of the literature. Dermatol Surg. 2004;30(7):1050-3.

19. Gilmore A, Kelsberg G, Safranek S. Clinical inquiries. What’s the best treatment for pyogenic granuloma? J Fam Pract. 2010;59(1):40-2.

20. Mirshams M, Daneshpazhooh M, Mirshekari A, et al. Cryotherapy in the treatment of pyogenic granuloma. J Eur Acad Dermatol Venereol. 2006;20(7):788-90.

21. Quitkin HM, Rosenwasser MP, Strauch RJ. The efficacy of silver nitrate cauterization for pyogenic granuloma of the hand. J Hand Surg [Am]. 2003;28(3):435-8.

22. Moon SE, Hwang EJ, Cho KH.Treatment of pyogenic granuloma by sodium tetradecyl sulfate sclerotherapy. Arch Dermatol. 2005;141(5):644-6.

23. Georgiou S, Monastirli A, Pasmatzi E, Tsambaos D. Pyogenic granuloma: complete remission under occlusive imiquimod 5% cream. Clin Experi Dermatol 2008;33(4):454-6.

24. Ezzell TI, Fromowitz JS, Ramos-Caro FA. Recurrent pyogenic granuloma treated with topical imiquimod. J Am Acad Dermatol 2005;54(5 Suppl):s244-5.

25. Rai S, Kaur M, Bhatnagar P. Laser: a powerful tool for treatment of pyogenic granuloma. J Cutan Aesthet Surg. 2011;4(2):144-7.

26. Lindenmüller IH, Noll P, Mameghani T, Walter C. CO2 laser-assisted treatment of a giant pyogenic granuloma of the gingiva. Int J Dent Hyg. 2010;8(3):249-52.

27. Hammes S, Kaiser K, Pohl L, et al. Pyogenic granuloma: treatment with the 1,064-nm long-pulsed neodymium-doped yttrium aluminum garnet laser in 20 patients. Dermatol Surg. 2012;38(6):918-23.

28. Sud AR, Tan ST. Pyogenic granuloma-treatment by shave-excision and/or pulsed-dye laser. J Plast Reconstr Aesthet Surg. 2010;63(8):1364-8.

29. Neff AG, Carter KD. Benign eyelid lesions. In: Yanoff M, Duker JS, Augsberger JJ, et al., eds. Ophthalmology, 3rd Edition. Edinburgh: Mosby Elsevier, 2009. 1422-33.

30. Sheehan DJ, Lesher JL. Pyogenic granuloma arising within a port-wine stain. Cutis. 2004;73(3):175-80.