A 53-year-old Man With Pyogenic Granuloma

Gary Goldenberg, MD

Disclosures

March 10, 2010

Discussion

Pyogenic granuloma (PG), also known as lobular capillary hemangioma, granuloma pyogenicum, tumor of pregnancy, eruptive hemangioma, and granulation tissue-type hemangioma, was first described in 1897 by 2 French surgeons, Poncet and Dor.[1] These lesions may occur at any age, and there is an equal sex distribution. PG develops more frequently during pregnancy and within preexisting vascular lesions. Approximately 2% of women develop pyogenic granuloma lesions during pregnancy, with gingival lesions during the first trimester being especially frequent.[2,3] PG has been said to arise in vascular malformations, within other hemangiomas, and within blood vessels[4,5,6] Patients who have received oral or topical isotretinoin therapy for acne have also been reported to develop PG lesions.[7,8] PG may also occur with methotrexate, indinavir, and anti-epidermal growth factor receptor antibodies.

The pathogenesis of PG is unclear, but clinical features suggest that these lesions may be related to reactive neovascularization. This is deduced from a clinical association with a preexisting injury or irritation, multiple eruptions and recurrences, and limited capacity for growth. Development during pregnancy and within preexisting vascular lesions suggests a role for angiogenic factors and hormonal stimuli in pathogenesis of PG.[1]

A classic clinical presentation includes rapid growth over several weeks or months and then stabilization. These lesions rarely grow larger than 1-2 cm. However, giant PGs have also been described; these may affect the skin and mucosa, be seen in areas of a burn, and occur in other vascular lesions.[9,10] PG usually presents as a friable, erythematous, sessile papule or nodule that bleeds easily with minimal trauma. The bleeding may be profuse. Secondary infection is possible and should be suspected if there is purulent drainage. The diagnosis of pyogenic granuloma is mostly clinical and is based on history of rapid growth and a typical appearance. The most common locations, in descending order, are gingiva, fingers, lips, face, and tongue.[11] These lesions are usually solitary. However, multiple satellite lesions may also be seen, especially after surgical treatment of the original PG.[12] Furthermore, disseminated and eruptive forms of PG have also been described in the literature.[13] The differential diagnosis includes other vascular tumors, such as capillary hemangioma; glomus tumors; warts; traumatized nevi; and, in the immunosuppressed patient, bacillary angiomatosis or Kaposi's sarcoma.

Histopathologic evaluation usually shows a polypoid or pedunculated neoplasm with central epidermal effacement. Central erosion or ulceration may also be seen. Crusting of the stratum corneum may be present, and bacterial forms can be seen in some cases. An epidermal collarette is usually visible and surrounds a dermal vascular proliferation. Dermal vessels are arranged in lobules that are composed of capillaries. Dermal vessels may be engorged with erythrocytes and hemorrhage into surrounding tissue may be seen. Mitotic figures may be seen in the capillary walls and do not denote a malignant process in the case of PG. Scarring from prior bleeding or treatment may also be evident in the dermis.

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