CASE #1: Pyogenic granuloma
Biopsy of our patient's nodule demonstrated pyogenic granuloma (also known as lobular capillary hemangioma), an aggregation of blood vessels that forms a papule or nodule. The etiology is unknown. As with a number of other dermatologic entities, the name is taxonomically incorrect—pyogenic granulomas are neither infectious nor granulomatous.
Patients are typically pregnant women or children of either gender. However, pyogenic granulomas can occur in any age group, with all races being equally affected. While most pediatric patients are younger than 5 years of age, the lesions rarely develop in those younger than 6 months old. Overall, pyogenic granuloma is relatively common. It represents 0.5% of all skin nodules in children and occurs in 1%-5% of pregnant women.
Initial presentation is a friable or glistening red papule that bleeds. It is often surrounded by a collarette of scale, as was seen with our patient. Erosion, ulceration, and crusting are also seen. Lesions grow rapidly and can range in size from a few millimeters to several centimeters in diameter (average diameter 6.5 mm).
The nodules may be polypoid or pedunculated. Pyogenic granuloma with satellitosis, a subcutaneous subtype (most common on the scapula), and disseminated lesions have also been reported. Subcutaneous growths usually develop on the arms; rarely, IV pyogenic granulomas may manifest as vascular polyps on the neck or upper extremities. Regressing lesions appear as soft, pink fibromas.
Pyogenic granulomas typically are not painful, but they can be sensitive to the touch. Patients will often present with a positive “Band-Aid sign,” the presence of three bandages arranged in a Union Jack on top of the papule or nodule, which persistently bleeds or weeps.
In children and other patients who are not pregnant, lesions commonly develop on the hands and feet, but they can occur on any area of the body. Other areas where lesions are often seen include the head and neck (specifically the gingiva, lips, nasal mucosa, and face). In pregnant women, pyogenic granulomas are frequently found along the maxillary intraoral mucosal surface, but any intraoral, perioral, and nonoral tissue may be involved. These growths are termed “pregnancy tumors.” The extremities may also be affected.
Trauma was once considered the primary cause of pyogenic granuloma; however, only 7% of patients give a history of trauma. As mentioned, lesions tend to develop during pregnancy (usually the second or third trimester); rarely do they occur in women taking oral contraceptives. Use of oral retinoids (acitretin, etretinate, or isotretinoin), topical retinoids, protease inhibitors, and capecitabine (a fluoropyrimidine) has also been implicated. Additional causative factors include vascular malformations, bacterial infection (Staphylococcus aureus is frequently present in the lesion), and viral infection. Pyogenic granulomalike lesions with Bartonella species seropositivity actually represent bacillary angiomatosis, an infection that resolves with antibiotic (macrolide) therapy.
A variety of conditions that resemble pyogenic granulomas must be ruled out. These include angioendothelioma, angiosarcoma, angiolymphoid hyperplasia with eosinophilia, atypical fibroxanthoma, bacillary angiomatosis, basal cell carcinoma, cherry hemangioma, dermatofibroma (eruptive), glomus tumor, granulation tissue, hemangioendothelioma, histoplasmosis (and other deep fungal infections), intravascular angiomatosis (Masson lesion), infantile hemangioma, Kaposi's sarcoma, malignant melanoma (particularly amelanotic melanoma), metastatic carcinoma of the skin, Spitz nevus, squamous cell carcinoma, and tufted hemangioma.
Most pyogenic granuloma lesions can be completely removed by excision, curettage, and cauterization or by pulsed-dye laser surgery. Cryotherapy, chemical cauterization with topical silver nitrate, or application of topical bexarotene or alitretinoin are convenient. Use of systemic steroids and interferon has also been noted. Imiquimod, an anti-angiogenic agent, should be effective, but its use has not been reported.
Recurrence after treatment is common (40%-50% of cases), regardless of the therapeutic modality used. This is because the feeding blood vessels extend deep into the dermis in a conelike manner.
Our patient's lesion was desiccated and scraped off with a curette. At one-month follow-up, the pyogenic granuloma had not returned.