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A 65-year-old man of Middle Eastern descent presents with a tender, weeping mass on his right palm. Since appearing 8 months ago, the lesion has enlarged into a 0.9-cm, pink pedunculated nodule with abundant serous crust. The patient has no significant history of trauma. His medical history is significant for atrial fibrillation, hypertension, coronary artery disease, congestive heart failure, and lung cancer, which was treated with right lobectomy. It is unclear what medications were used to treat his lung cancer. His current medications include metoprolol, lisinopril, allopurinol, aspirin, and digoxin. The patient also presents with additional pink, scaly plaques on his right ankle, consistent with nummular eczema.
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Lobular capillary hemangioma (LCH), also known as pyogenic granuloma, is a benign vascular tumor that most commonly arises in tissues such as the skin and mucous membranes and occasionally is found subcutaneously, intravascularly, or in the gastrointestinal tract.1,2 It can develop spontaneously in sites of injury or within capillary malformations.1
Lobular capillary hemangioma typically begins as a small, red papule that may grow over weeks to months before stabilizing in size. The pedunculated papule is friable and often undergoes ulceration.3 A collarette of scales often is present at the base of the lesion, but this sign is not unique to this entity.3 The lesions can bleed profusely after unavoidable trauma.3 The diameter varies from a few millimeters to several centimeters, and satellite lesions may develop around a primary lesion or disseminate.3
Mucosal LCH is seen most commonly within the oral cavity.3 Cutaneous LCH typically appears on the trunk and extremities in adults and on the head and neck region in children.3
Histologic examination may be warranted to diagnose LCH. If the lesion is excised, it should be sent for histopathologic confirmation to rule out malignancy. Histologically, LCH consists of aggregates of capillary-sized vessels that develop within highly vascular granulation tissue with lobules of thin-walled capillaries embedded within a loose fibrous stroma.3 Scattered fibroblasts and inflammatory infiltrate often are found.3 The overlying epidermis is often thinned and develops erosion and ulceration in more severe cases.3 These lesions are neither pyogenic nor granulomatous; thus, the term pyogenic granuloma is not accurate. To correct the misleading terminology, Mills et al suggested using the more descriptive term lobular capillary hemangioma.4
Atypical lesions may necessitate the use of immunohistochemistry staining to rule out other causes.3 These lesions stain positive for vascular markers such as CD31, CD34, and factor VIII antigen but negative for glucose transporter-1, unlike infantile hemangioma.3,5
Pyogenic granuloma may occur in all age groups and there is no clear gender predominance.2 Reports conflict regarding the epidemiologic pattern of disease.2,6,7
The cause of LCH is unknown and no single pathway has been defined for pathogenesis of the lesions. Proposed mechanisms include an imbalance of proangiogenic and antiangiogenic factors that leads to rapid proliferation of neovascular, friable, and lobular capillaries.3 Reactive granulation tissue from minor trauma and other predisposing factors, such as infection and preexisting vascular malformations, may contribute to pathogenesis.3 In pregnant patients, hormonal factors appear to play a role.2,8
Certain variants of LCH are associated with medication use. The most common medication-associated variant is multiple periungual pyogenic granuloma, which also is found in patients with other chronic dermatoses, such as atopic dermatitis and psoriasis.3 Drugs implicated most often include systemic and topical retinoids and antiretroviral, antineoplastic, and immunosuppressive agents.3 It is unclear whether the presenting patient had received chemotherapy or any other potentially causative agents previously because he did not follow up after biopsy and diagnosis.
The differential diagnosis of LCH should include certain red flag lesions such as melanoma, squamous cell carcinoma, basal cell carcinoma, angiosarcoma, and malignant lymphoma. In an immunosuppressed individual, bacillary angiomatosis and Kaposi sarcoma should be included in the differential diagnosis. Benign lesions that present similarly to LCH include other capillary hemangiomas, irritated nevi, Spitz nevi, warts, granulation tissue from minor trauma, glomus tumor, and angiolymphoid hyperplasia with eosinophilia.1,3 Histopathology will help differentiate these conditions.
Despite its benign nature, LCH may necessitate treatment to alleviate discomfort, bleeding, and/or obstruction of other structures. The selection of treatment should be made individually, depending on the size and severity of the lesions as well as patient characteristics and preferences. Treatment typically consists of excision, which results in the lowest rate of recurrence.1 Findings by Akamatsu et al suggest that shave excision followed by carbon dioxide laser ablation is linked to lower recurrence rates and is significantly less painful than excision and suture.9 Other treatments include curettage, electrocautery, radiosurgery, cryosurgery, sclerotherapy, and laser treatment. Successful photodynamic therapy with 5-aminolevulinic acid has been reported for a single LCH lesion on a finger; however, the advantage of this treatment compared with laser ablation has not been proven.1
Dominique Jacobs, BS, is a fourth-year medical student and aspiring dermatologist attending the Philadelphia College of Osteopathic Medicine; Katrina Hansen, DO, is the chief dermatology resident at Beaumont Farmington Hills in Michigan. Her interests include medical and surgical dermatology.
References
1. Wollina U, Langner D, França K, Gianfaldoni S, Lotti T, Tchernev G. Pyogenic granuloma – a common benign vascular tumor with variable clinical presentation: new findings and treatment options. Open Access Maced J Med Sci. 2017;5(4):423-426. doi:10.3889/oamjms.2017.111
2. Plachouri KM, Georgiou S. Therapeutic approaches to pyogenic granuloma: an updated review. Int J Dermatol. 2019;58(6):642-648. doi:10.1111/ijd.14268
3. Sarwal P, Lapumnuaypol K. Pyogenic granuloma. In: StatPearls. StatPearls Publishing; 2021. Updated December 5, 2020. Accessed June 28, 2021. https://www.ncbi.nlm.nih.gov/books/NBK556077
4. Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma. A study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol. 1980;4(5):470-479.
5. Seyedmajidi M, Shafaee S, Hashemipour G, Bijani A, Ehsani H. Immunohistochemical evaluation of angiogenesis related markers in pyogenic granuloma of gingiva. Asian Pac J Cancer Prev. 2015;16(17):7513-7516. doi:10.7314/apjcp.2015.16.17.7513a
6. Harris MN, Desai R, Chuang TY, Hood AF, Mirowski GW. Lobular capillary hemangiomas: an epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol. 2000;42(6):1012-1026.
7. Koo MG, Lee SH, Han SE. Pyogenic granuloma: a retrospective analysis of cases treated over a 10-year. Arch Craniofac Surg. 2017;18(1):16-20. doi:10.7181/acfs.2017.18.1.16
8. Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral pyogenic granuloma: a review. J Oral Sci. 2006;48(4):167-175.
9. Akamatsu T, Hanai U, Kobayashi M, Miyasaka M. Pyogenic granuloma: a retrospective 10-year analysis of 82 cases. Tokai J Exp Clin Med. 2015;40(3):110-114.
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