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.
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
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
• 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
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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.
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