A white man aged 59 years presented with a “thorn blister” on his finger that appeared two months prior. The man worked in the produce section of a large supermarket, and he believed that he was stuck by a thorn while handling fruit, causing a red blister that initially grew rapidly but then remained stable in size.
The patient reported no associated pain, itching, or numbness, although he complained that the blister frequently bled and that significant pressure and bandaging was required to stop the bleeding. There was no personal or family history of skin cancer.
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The patient was diagnosed with pyogenic granuloma. Clinical examination of the lesion revealed a 7-mm friable erythematous nodule with a thin collarete of scale at the periphery, located on the lateral aspect of the left index finger.
The patient was advised to have a shave biopsy done, allowing for removal of the lesion and confirmation of the clinical diagnosis pyogenic granuloma (PG).
Also known as a lobular capillary hemangioma, PG is a very common benign proliferation of blood vessels within the skin or mucous. The condition was first described in 1897 by two French surgeons. Despite its name, a PG is neither pyogenic/infectious nor granulomatous. The lesion typically grows quickly and is thus often suspected to be a cutaneous malignant tumor. It evolves into a semi-firm, red, exophytic papule or nodule.
The overlying skin may be intact, ulcerated, or broken, at times forming a unique collarete surrounding the lesion. Although asymptomatic, patients may complain of profuse bleeding that occurs spontaneously or from minor indirect trauma to the lesion.
PG occurs most often on the fingers, hands, upper trunk, and face. In addition, it is seen rather frequently in the oral cavity. PG is the most common benign tumor of the gingiva.1 Other common sites in the oral cavity include the lips, tongue and buccal mucosa. Rarely, PG may proliferate internally in the GI tract, larynx, or cornea. At times, several smaller satellite lesions may emerge after the appearance — or even disappearance — of the primary lesion.2
Incidence is greatest in school-aged children and young adult women, although the condition may occur at any age. There is a slightly increased prevalence in the female sex.
Although PG has no definite known cause, mechanical trauma is often reported to occur prior to onset, and this may explain the frequent incidence of lesions in areas prone to trauma, particularly the hands and mouth. Similarly, PGs have been reported to occur on the penile shaft following circumcision.3
An embedded foreign body is commonly discovered to be the cause of a recurring PG. Hormonal changes, such as those that occur with pregnancy or oral contraceptive use, are also associated with the development of PG. Granuloma gravidarum and pregnancy tumor are unique descriptions used for lesions occurring during pregnancy that are typically seen on the oral mucosa or gingiva and generally occur in the second or third trimesters.4
Systemic retinoids, used in the treatment of several chronic dermatologic conditions, and indinavir (Crixivan), used in antiretroviral therapy, have also been implicated in its pathogenesis. Rare cases of numerous exuberant PGs have been described in patients being treated with isotretinoin (Accutane) for acne vulgaris.5 There is controversy as to whether infection with the Bartonella species plays an etiologic role.6
Because the presentation of a PG can mimic that of other benign conditions (e.g. cherry angioma, glomus tumor, bacillary angiomatosis) or more serious malignant conditions (e.g. amelanotic malignant melanoma, Kaposi’s sarcoma, Spitz nevus, basal cell carcinoma), microscopic confirmation of the diagnosis is imperative. Histopathologic findings of lobules of capillaries and venules separated by edematous septa with a mixed inflammatory cell infiltrate are characteristic of a PG.
Although spontaneous resolution has been known to occur, surgical removal is the recommended treatment. Shave biopsy is generally the preferred option, allowing for acceptable cosmetic outcome and histopathologic analysis of the specimen. After removal, electrodessication of the base of the lesion is recommended to control bleeding, and studies have suggested that it may prevent recurrences. Recurring PGs (a common phenomenon) that are refractory to standard treatments are best removed with a full-thickness skin excision.
Second-line treatments include pulsed dye laser therapy, silver nitrate cautery, cryotherapy and sclerotherapy with monoethanolamine oleate. Topical medications that have been tried with varying success include imiquimod (Aldara) and tretinoin.
Systemic steroids may be indicated for recurrent giant PG or for lesions with significant satellitosis. If a medication has been implicated as the trigger, cessation of the medication may induce spontaneous regression. Granuloma gravidarum may resolve after parturition.
Patients should be advised that PG is a benign tumor and histopathology will confirm the diagnosis. After treatment, the surgical sites should be monitored closely for uncontrolled bleeding or signs of infection. If evidence of recurrence appears, patients should return promptly for treatment. If a medication has been implicated as a cause, patients should be educated to be cautious with future usage.
The patient in this case was treated with shave removal of the lesion, and histopathology confirmed the diagnosis of PG. Three months later, he returned with recurrence — albeit smaller in size — of the primary lesion.
Various treatment options were discussed, and the patient opted for repeat shave removal with thorough needle hyfrecation of the base. The lesion was treated successfully with a minimal scar now evident at the site.
Esther Stern, NP-C, is a family nurse practitioner at Advanced Dermatology & Skin Surgery, P.C., in Lakewood, N.J. The author has no relationships to disclose regarding the content of this article.
1. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006;48:167-175.
2. Zaynoun ST, Juljulian HH, Kurban AK. Pyogenic granuloma with multiple satellites. Arch Dermatol. 1974;109:689-691.
3. Paller AS, Mancini AJ. Hurwitz Clinical Pediatric Dermatology. 4th ed. Philadelphia, Pa.: Elsevier Saunders; 2011:281-282.
4. James WD, Berger TG, Elston DM. Errors in metabolism. In: Andrews’ Diseases of the Skin: Clinical Dermatology. 10th ed. Philadelphia, Pa.: Saunders-Elsevier; 2006:808.
5. Lee J, Lynde C. Pyogenic granuloma: pyogenic again? Association between pyogenic granuloma and Bartonella. J Cutan Med Surg. 2001; 5:467-470.