A 28-year-old healthy white woman with no significant past medical history presents with an enlarging papule on her right lateral neck. She describes a 1- to 2-mm pink papule that grew to approximately 10 mm within the past week. With minimal rubbing or trauma, the papule intermittently bleeds. It is otherwise nontender and nonpruritic. She has no history of skin cancer and is taking oral contraceptives. Physical examination shows a pink, friable papule on a stalk on the right lateral neck. There are no other similar lesions seen on examination.
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Pyogenic granuloma (PG), also known as lobular capillary hemangioma, is a common vascular proliferation of the skin or mucous membranes that typically presents as a solitary red papule or polyp. These lesions typically grow over a course of several weeks to months and rarely exceed 1 cm in diameter. The most common sites are the gingiva, fingers, lips, face, and tongue.1,2
Approximately one-third of these lesions are thought to develop following trauma.1 The majority of PGs originate from the dermis or mucous membranes, but there are case reports of PGs of intravascular or subcutaneous origin.3,4 PGs commonly develop in children and young adults, but they can occur at any age and have a slight male predominance. Gingival lesions, however, present more commonly in pregnant women.1,2
The term pyogenic granuloma is a misnomer. There is no infectious agent or granulomatous appearance on histology. PGs are better described as a friable reactive neovascularization or exuberant overgrowth of granulation tissue. They often ulcerate and bleed with minimal trauma. There are reported correlations between PGs and medications, including systemic retinoids, indinavir, capecitabine, and epidermal growth factor receptor inhibitors.1 Due to increased prevalence of PGs in pregnancy, known as granuloma gravidarum or pregnancy tumors, a hormonal influence has been postulated, but there are no studies to support this theory.3,5
The classic histologic appearance of this lesion is an exophytic proliferation of capillaries arranged in a lobular pattern. The capillaries are lined by endothelial cells and rimmed by pericytes. The surrounding stroma is fibromyxoid with scattered fibroblasts. The capillaries are arranged in lobules that are separated by thick, intervening bands of dense fibrous tissue. There is often an epithelial collarette that delineates the margins of this lesion.1 Over time, the epidermis frequently starts to become thin and can erode. Heavy, superimposed staphylococcal colonization is common.2
The differential diagnosis for pyogenic granuloma includes amelanotic melanoma, bacillary angiomatosis or Kaposi sarcoma in immunosuppressed individuals, glomus tumor, hemangiomas, and irritated melanocytic nevi and warts. A thorough history, including immune status, history of malignancy (eg, skin cancers), medications, and hormonal patterns or supplementations, can help with diagnosis of pyogenic granuloma. However, pink papules (especially bleeding lesions) must be biopsied to rule out malignancy, particularly amelanotic malignant melanoma. From a dermatopathology prospective, the differential diagnosis histologically includes vascular lesions such as bacillary angiomatosis and angiosarcoma.6 There are no special immunohistochemical stains that are helpful, but combining the appropriate clinical presentation and a benign-appearing histology often are sufficient to arrive at the correct diagnosis.
Treatment for PG is typically shave excision, followed by electrofulguration or silver nitrate application to the base. If the lesion is not completely removed or destroyed, it may recur and form adjacent satellite lesions.2 For smaller PGs, pulsed dye laser or other lasers with vascular targets can be effective and safe.1 Other previously successful alternatives include sclerotherapy and imiquimod under occlusion.2
In our case, the patient underwent shave excision with electrofulguration under local anesthesia. She tolerated this procedure well, and the specimen was sent for histologic confirmation to rule out amelanotic melanoma. A pregnancy test was also performed, the result of which was negative, and the patient continued taking her oral contraceptives as prescribed. She has had no recurrence or new lesions develop.
Tiffany Shih, MD, is a resident physician at the University of Minnesota in Minneapolis.
- Bolognia JL, Jorizzo JL, Schaffer JV. Dermatology. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2012.
- James WD, Berger TG, Elston D. Andrews’ Diseases of the Skin: Clinical Dermatology. 11th ed. Philadelphia, PA: Saunders Elsevier; 2011.
- Harris MN, Desai R, Chuang TY, et al. Lobular capillary hemangiomas: an epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol. 2000;42(6):1012-1016.
- Fortna RR, Junkins-Hopkins JM. A case of lobular capillary hemangioma (pyogenic granuloma) localized to the subcutaneous tissue and a review of the literature. Am J Dermatopathol. 2007;29(4):408-411.
- Demir Y, Demir S, Aktepe F. Cutaneous lobular capillary hemangioma induced by pregnancy. J Cutaneous Pathol. 2004;31(1):77-80.
- Brinster NK, Liu V, Diwan H, McKee PH. Dermatopathology: A Volume in the High Yield Pathology Series. 1st ed. Philadelphia, PA: Elsevier Saunders; 2011.