Answer: Can you identify this condition?

3. Pyogenic granuloma

Pyogenic granuloma (PG), or lobular capillary hemangioma, is a common benign vascular neoplasm of the skin and mucosa.1–5 It is most frequently found on the head and neck of children and young adults1–3,5; however, it can occur anywhere on the body at any age.2,3

Patients often present with a shiny, red, pedunculated nodule that grows rapidly over weeks to months.1–5 Bleeding, mild discomfort, and cosmetic concerns are the most common complaints.1–5

The exact etiology of PG is unknown.1–3,5 Previous trauma, surgery, and chronic irritation at the presenting site have all been associated with PG,1–5 as have chalazia. Other potential causes include Bartonella, Gram-positive bacilli, and viral infections.2,5 Female hormones have also been associated with mucosal PG, evidenced by higher rates of the condition among women who are pregnant or taking oral contraceptives.2,3,5 This association is thought to be due to concomitantly high levels of angiogenic factors, such as vascular endothelial growth factor.5 It has been postulated that the propensity of PG to occur on the head and neck is a result of the rich vascular supply in that area in combination with trauma to the mouth or lips from chewing.3 The fingers are also a common site for PG owing to higher incidences of microtrauma.3

Pyogenic granuloma is a misnomer, for it is neither pyogenic nor granulomatous.1,2 Histologically, PG is identical to granulation tissue. It consists of highly vascularized connective tissue, with capillaries, venules, and inflammatory cells forming an edematous matrix.1–3,5 As the PG matures, a fibromyxoid stroma separates the lesion into lobules containing aggregates of capillaries and venules with plump endothelial cells.1–3,5

Management

Several treatments exist for PG, each differing in cosmetic outcome and recurrence rate. There is agreement in the literature that excision and closure results in the lowest recurrence rate.2–5 Other techniques include topical and intralesional steroids with or without antibiotics,4 cryotherapy, shave excision, curettage, cautery, silver nitrate, laser,2–5 and sclerotherapy with ethanolamine oleate.3,5 If a shave excision is performed, curettage with cautery or laser coagulation is recommended to decrease the likelihood of recurrence.4 Whatever technique is used, it is important to provide a tissue sample for histopathological analysis to exclude the possibility of other, potentially life-threatening, conditions.2,3,5

The differential diagnosis for PG includes amelanotic melanoma, squamous cell carcinoma, basal cell carcinoma, Kaposi sarcoma, metastatic carcinoma, angiosarcoma, hemangioma, and bacillary angiomatosis.3,5 If left untreated, most PGs will spontaneously infarct and regress with time.2,3,5 Pyogenic granulomas are not known to have the potential for malignant degeneration.2

Our patient was treated with a tobramycin-prednisolone ointment 4 times daily for 4 weeks with no resolution of the PG. During this time, the lesion increased in size so that it spontaneously flipped out of the inferior fornix and hung over the lower lid. The patient was able to manually place the lesion back into the inferior fornix. Definitive management consisted of excision and closure, with good results.

Conclusion

Pyogenic granuloma is a benign vascular neoplasm and is often distressing to patients. Although it is usually self-limiting, treatment is often required. Regardless of the chosen treatment, it is important to provide a tissue sample for histopathological review to rule out a potentially life-threatening diagnosis.