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Pyogenic granuloma

Pyogenic granuloma, also known as lobular capillary hemangioma, is a common, benign vascular tumor that presents as a rapidly growing, raised, red or reddish-purple nodule on the skin or mucous membranes, often prone to bleeding due to its friable nature.^[1]^[2] Despite its name, pyogenic granuloma is not caused by infection but rather by an overgrowth of blood vessels in response to various stimuli, typically measuring 2 to 10 millimeters in diameter and developing over a period of weeks.^[1]^[2] It most frequently affects children, adolescents, young adults, and pregnant individuals, with a peak incidence in the second decade of life and a slight male predominance in cutaneous cases.^[2] Common sites include the hands, fingers, head, neck, and oral cavity, particularly the gingiva, where it may appear as a pedunculated lesion with a smooth or slightly ulcerated surface.^[1]^[2] The exact etiology remains unclear, but local trauma, such as minor injuries or surgical sites, is implicated in up to 7% of cases, while hormonal influences—evident in pregnancy-related lesions termed granuloma gravidarum—affect up to 5% of pregnant women and often regress postpartum.^[2] Certain medications, including retinoids, protease inhibitors, and epidermal growth factor receptor (EGFR) inhibitors, have also been associated with its development.^[1]^[2] Histopathologically, it features lobular aggregates of capillary-sized vessels within granulation tissue, accompanied by inflammatory cells and a collarette of epidermal scaling at the base.^[2] Diagnosis is primarily clinical, based on the characteristic rapid growth and appearance, though dermoscopy or biopsy may be employed to rule out differentials such as amelanotic melanoma, basal cell carcinoma, or Kaposi sarcoma.^[1]^[2] Treatment typically involves surgical excision with cautery to minimize recurrence, which occurs in up to 40% of cases, or alternatives like cryotherapy, laser ablation, or topical timolol for smaller lesions.^[1]^[2] Although harmless and lacking malignant potential, pyogenic granulomas warrant management due to cosmetic concerns, frequent bleeding, and potential for local irritation.^[2]

Clinical Features

Signs and Symptoms

Pyogenic granuloma manifests as a rapidly growing, friable nodule that develops over days to weeks, forming either a pedunculated or sessile lesion typically measuring 2-10 mm in diameter.^[2]^[3] The lesion exhibits a bright red to violaceous color with a glistening, moist surface resembling raw tissue; it may develop a yellowish crust or collarette of scale at the base. Due to its hypervascular nature, the nodule has a marked tendency to bleed profusely with even minor trauma.^[2]^[3] These lesions commonly arise on the gingival mucosa, the most frequent site within the oral cavity, as well as on the fingers, hands, arms, face, and conjunctiva; occurrences on the trunk or legs are less common.^[4]^[2]^[5] Pregnancy-associated pyogenic granulomas, often termed granuloma gravidarum, tend to be larger and multiple, primarily affecting the gingiva during the second or third trimester, with many resolving spontaneously postpartum.^[2]^[4] The lesions are generally asymptomatic, though they may cause pain if subjected to trauma or secondary infection.^[4]

Epidemiology

Pyogenic granuloma is a common benign vascular lesion, representing approximately 0.5% of all childhood skin nodules and accounting for 3-7% of biopsied oral lesions in some populations, though exact overall incidence rates remain unknown due to its frequent occurrence in outpatient settings without systematic reporting.^[6]^[7] It shows higher prevalence in children and young adults, with many cases arising from minor trauma or irritation, but population-level data are limited by underdiagnosis of smaller lesions.^[2] The condition exhibits a bimodal age distribution, peaking in the first two decades of life, where up to 50-60% of cases occur in patients under 20 years, particularly around ages 6-10 for pediatric presentations; a second peak is observed in women during pregnancy, often in the second or third trimester.^[2]^[1] It is rare in infants under 1 year, with mean onset ages reported as low as 6-7 years in pediatric cohorts before incidence declines with advancing age in non-pregnant adults.^[8] Overall, there is a slight female predominance with a female-to-male ratio of approximately 1.5:1, though some studies report near parity (1:1.2) for cutaneous lesions and greater female bias (up to 2:1) for mucosal sites; this disparity is more pronounced in pregnancy-related cases due to hormonal influences.^[2]^[9] No strong racial or ethnic predilections have been identified, with cases reported across diverse populations without significant variation; however, oral pyogenic granulomas are more frequent in regions or communities with poor dental hygiene, where chronic irritation from plaque or trauma is prevalent.^[2]^[10]

Etiology and Pathogenesis

Causes and Risk Factors

Pyogenic granuloma is often triggered by minor trauma, such as injuries, burns, or sites of recent surgery, which may lead to aberrant wound healing and subsequent capillary proliferation.^[2] Studies indicate that trauma precedes lesion formation in 7% to 14% of cases, with a higher association (up to 23%) observed in lesions on the fingers.^[11] Hormonal influences play a significant role, particularly elevated estrogen levels during pregnancy, which can result in granuloma gravidarum, a variant commonly affecting the oral mucosa in the second or third trimester.^[2] This condition occurs in approximately 5% of pregnancies and is twice as prevalent in women compared to men for mucosal sites.^[12] Additionally, use of oral contraceptives has been linked to the development of oral pyogenic granulomas, likely due to similar estrogen-mediated effects.^[13] Certain systemic medications are associated with pyogenic granuloma formation, including retinoids such as isotretinoin, protease inhibitors like indinavir, and calcium channel blockers such as amlodipine or nifedipine, which may induce gingival overgrowth presenting as these lesions.^[2]^[14] Other implicated drugs include antineoplastics (e.g., capecitabine, taxanes), EGFR inhibitors, BRAF inhibitors (e.g., vemurafenib), and immunosuppressants (e.g., cyclosporine).^[11]^[15] Infectious or inflammatory stimuli are rarely involved, with occasional reports of bacterial association, such as chronic Staphylococcus aureus infection contributing to lesion development, though the condition is not truly pyogenic.^[16]^[17] Viral theories, including human papillomavirus (HPV), remain unproven despite some historical speculation.^[15] Other risk factors encompass chronic irritation from sources like indwelling devices or laser treatments, as well as underlying vascular anomalies such as microscopic arteriovenous malformations.^[11]^[16] Lesions have also been noted in association with skin conditions involving repeated trauma, though specific links to acne are primarily through medication side effects rather than the condition itself.^[2] No clear genetic predisposition has been identified for pyogenic granuloma, with familial cases being exceedingly rare and no increased risk observed among relatives.^[18] Consequently, most cases are considered idiopathic, arising without an identifiable trigger.^[2]

Pathophysiology

Pyogenic granuloma is characterized by a benign vascular proliferation consisting of a lobular arrangement of capillaries exhibiting endothelial cell hyperplasia, supported by a fibrous stroma and accompanied by an inflammatory infiltrate. This structure arises from an exuberant reactive process rather than neoplastic growth, with the lobules formed by clusters of capillary-sized vessels centered around feeder vessels within granulation-like tissue. The lesion's friable nature stems from this highly vascular composition, which lacks a well-defined capsule and often features surface ulceration.^[2] The key cellular processes involve dysregulated angiogenesis, primarily driven by vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), leading to an imbalance between pro-angiogenic and anti-angiogenic regulators. These factors promote rapid endothelial cell proliferation and new vessel formation, resulting in the lesion's characteristic neovascular growth. Elevated expression of VEGF and bFGF has been observed in lesion tissues compared to normal gingiva or periodontitis-affected areas, underscoring their role in sustaining the proliferative phase.^[2]^[19] An associated inflammatory response contributes to the lesion's pseudopyogenic appearance, with early involvement of polymorphonuclear leukocytes transitioning to a chronic infiltrate of lymphocytes, plasma cells, and mast cells within the granulation tissue framework. This inflammation supports the vascular expansion but does not indicate infection, as the term "pyogenic" is a historical misnomer.^[2]^[20]^[21] Spontaneous regression is rare, occurring primarily in postpartum cases due to hormonal withdrawal, while most lesions persist owing to ongoing angiogenic stimuli that prevent natural involution. Molecular insights reveal upregulation of the Ras pathway, with somatic activating mutations in RAS genes (such as HRAS) driving vascular tumor formation via the MAPK/ERK signaling cascade. Additionally, matrix metalloproteinases (MMPs) are overexpressed in lesion tissue, facilitating extracellular matrix remodeling and stromal spacing that accommodate vascular proliferation.^[2]^[22]^[23]

Diagnosis

Clinical Evaluation

The clinical evaluation of pyogenic granuloma begins with a thorough history taking to identify potential triggers and contextual factors. Clinicians should inquire about recent trauma or irritation to the site, as these are common precipitants; current or recent medication use, such as retinoids, protease inhibitors, or antineoplastics; pregnancy status, given the higher incidence in pregnant individuals; and episodes of spontaneous or traumatic bleeding, which are characteristic due to the lesion's friable vascular nature.^[2]^[12] These historical elements help correlate the lesion with common sites like the head, neck, hands, or oral mucosa, where bleeding tendency is prominent.^[2] Physical examination focuses on the lesion's macroscopic features to support a presumptive diagnosis. The typical presentation is a solitary, raised, red to purple papule or nodule, ranging from a few millimeters to 1-2 cm in size, often pedunculated with a narrow base and exhibiting high vascularity that may lead to easy bleeding upon minor trauma. Assessment includes evaluating color (bright red if superficial, violaceous if deeper), surface (smooth, moist, or ulcerated), attachment (pedunculated or sessile), and surrounding skin for an epidermal collarette scale at the base. Dermoscopy enhances this evaluation by revealing characteristic patterns, such as a white rail-line (collarette) at the periphery, red homogeneous areas or lacunae representing vascular spaces, and occasional white intersecting lines indicating fibrous septa; these features are present in up to 85% of cases and aid in distinguishing from mimics.^[2]^[12]^[24] Differential diagnosis is crucial, as pyogenic granuloma can mimic several benign and malignant lesions, necessitating careful distinction based on clinical and dermoscopic clues. Basal cell carcinoma often presents with pearly, rolled borders and telangiectasias rather than the friable, pedunculated growth of pyogenic granuloma. Squamous cell carcinoma appears indurated with a keratinous surface and lacks the rapid onset and bleeding propensity. Amelanotic melanoma is typically asymmetric with irregular borders and less tendency to bleed profusely, often requiring dermoscopic assessment for polymorphous vessels. Kaposi sarcoma manifests as purplish, multifocal plaques in immunocompromised patients, contrasting with the solitary, exophytic nature of pyogenic granuloma.^[2]^[12]^[25] Biopsy is indicated when atypical features are present, such as unusually rapid or large growth, significant ulceration, prolonged persistence, irregular borders, or occurrence in older adults without clear trauma history; in these scenarios, excisional or incisional biopsy is recommended to rule out differentials like melanoma or carcinoma.^[2]^[12]^[26] Imaging is rarely required for superficial lesions but may be employed for deeper or atypical presentations to exclude underlying vascular malformations. High-resolution ultrasound can delineate the lesion as a hypoechoic mass with increased vascularity, helping differentiate from arteriovenous malformations or other anomalies without flow voids.^[27]^[28] Routine laboratory tests are not necessary for diagnosis, as pyogenic granuloma is primarily a clinical entity; however, they may be pursued if systemic associations, such as immunosuppression or endocrine disorders, are suspected based on history.^[2]^[29]

Histopathology

Grossly, pyogenic granuloma presents as a polypoid excisional specimen exhibiting a lobular architecture, often with a pedunculated or sessile base, friable surface, and potential ulceration leading to easy bleeding.^[20]^[2] Microscopically, the hallmark features include lobules of capillary-sized vessels arranged in a lobular pattern within an edematous or loose fibrous stroma, lined by plump, bland endothelial cells with frequent mitoses but no atypia; the surface is frequently ulcerated, accompanied by fibrinopurulent exudate and overlying epidermal collarette.^[20]^[2]^[12] The inflammatory infiltrate is mixed, comprising neutrophils, lymphocytes, plasma cells, and mast cells, resembling granulation tissue; in older lesions, fibrosis develops with fibrous septa separating the vascular lobules.^[20]^[2] Key diagnostic criteria emphasize the absence of cytologic atypia or significant mitoses beyond endothelial proliferation, distinguishing it from hemangioma (which lacks the organized lobular pattern) and angiosarcoma (which shows malignant features like atypia and invasion).^[20]^[2] Immunohistochemically, endothelial cells stain positively for CD31 and CD34, confirming vascular origin, while the Ki-67 proliferation index remains low, around 5%.^[2]^[30] Among variants, the subcutaneous type extends deeper into the dermis or subcutaneous tissue without surface ulceration, maintaining the lobular capillary architecture; it may mimic bacillary angiomatosis, which can be differentiated by the presence of Warthin-Starry stain-positive bacteria in the latter.^[20]^[31]^[32]

Treatment and Management

Nonsurgical Options

For small, asymptomatic pyogenic granulomas, particularly those arising during pregnancy, observation is a viable initial approach, as these lesions may regress spontaneously postpartum without intervention.^[2] In such cases, conservative management allows for natural resolution while monitoring for complications like bleeding or growth.^[2] Topical therapies offer a noninvasive option for smaller lesions, especially in children or cosmetically sensitive areas. Timolol 0.5% gel or solution, applied twice daily for 2-4 weeks, has demonstrated resolution rates of up to 77% in ophthalmic and periungual cases, with minimal adverse effects.^[29] Similarly, topical propranolol 1% cream, used twice daily, achieves complete resolution in 60% of cases including pediatric patients within 1-2 months, leveraging its antiangiogenic properties.^[33] Imiquimod 5% cream, applied once daily for 4-8 weeks, induces local inflammation leading to regression in therapy-resistant lesions, with partial to complete resolution in 80% of treated children and low scarring risk.^[34] Intralesional injections provide targeted treatment for lesions under 5 mm, with success rates varying by agent. Corticosteroids such as triamcinolone acetonide (10-40 mg/mL) are administered every 2-4 weeks, promoting regression through anti-inflammatory effects, as seen in eyelid and oral cases with near-complete resolution after 1-3 sessions.^[29] Sclerosing agents like sodium tetradecyl sulfate (16% resolution) or polidocanol (73% resolution), injected similarly, achieve varying resolution rates of 16-100% in 1-2 sessions by inducing vascular occlusion, particularly effective for recurrent or vascular-rich lesions depending on the agent.^[29] Chemical cauterization suits superficial lesions to control bleeding and promote involution. Silver nitrate application, often in 1-2 sessions, yields 90% resolution when combined with minimal debridement, though temporary skin discoloration may occur.^[29] Trichloroacetic acid (50-70%), applied focally every 1-2 weeks, chemically ablates tissue in small lesions, with efficacy enhanced when following topical beta-blockers.^[35] Laser therapy targets vascular components effectively for lesions in delicate sites. Pulsed dye laser (585-595 nm), delivered in 1-3 sessions, clears 25-67% of cases by selective photothermolysis, with minor side effects like erythema.^[29] Nd:YAG laser suits deeper lesions, achieving 44-74% resolution in 1-2 sessions, though it carries risks of pain and scarring.^[29] Alternative conservative approaches, such as common salt application, have shown effectiveness with low recurrence (8% at 3 months) in recent studies as of 2025.^[36] These nonsurgical options are preferred for pediatric patients, facial locations, or those seeking to avoid excision, with overall recurrence rates of 10-15% depending on lesion size and follow-up.^[37]

Surgical Interventions

Curettage followed by electrocautery is a first-line surgical approach for most pyogenic granulomas, involving scraping of the lesion with a curette and subsequent thermal destruction of the base using an electrocautery device to achieve hemostasis. This method is particularly suitable for small, pedunculated lesions in non-cosmetically sensitive areas and typically includes cautery of a 1-2 mm margin around the base to reduce recurrence risk. Studies report success rates of 85-95% with this technique, though recurrence occurs in approximately 10% of cases due to incomplete removal.^[38]^[2] Surgical excision entails full-thickness removal of the lesion with a margin of normal tissue, followed by primary closure using sutures, providing a specimen for histopathological confirmation. It is preferred for larger lesions exceeding 1 cm, recurrent cases, or subcutaneous variants, where deeper involvement necessitates complete excision to minimize regrowth. Recurrence rates are low at 2.94-4%, making it the most reliable option among surgical methods for these indications.^[37]^[38] Cryotherapy uses liquid nitrogen to freeze the lesion, typically in 1-2 cycles of 10-20 seconds each, causing tissue necrosis and sloughing. It is effective for small oral pyogenic granulomas due to its simplicity and minimal bleeding, but recurrence rates can be as low as 1.62%, particularly with complete treatments.^[37]^[39] Ablative methods include CO2 laser vaporization, which precisely ablates the lesion layer by layer with minimal thermal damage to surrounding tissue, offering good cosmetic outcomes in sensitive areas. Electrosurgery complements these by providing hemostasis through high-frequency current. Both are suitable for vascular lesions, with low recurrence when margins are adequately treated, though multiple sessions may be needed for thicker growths.^[40]^[2] Post-procedure care involves applying a pressure dressing to control bleeding and promote healing, with topical or oral antibiotics prescribed if signs of infection are present. Patients are advised to keep the site clean and dry, avoiding trauma, and to attend follow-up visits at 1-2 weeks to assess healing and detect early recurrence.^[2]^[41] Complications from surgical interventions include scarring in 5-10% of cases, particularly with excision, as well as infection and post-inflammatory pigment changes. Oral sites carry a higher risk of complications due to salivary contamination and mechanical irritation, potentially increasing infection rates.^[41]

History and Nomenclature

Historical Development

Pyogenic granuloma was first reported in 1897 by French physicians Antonin Poncet and Louis Dor, who described it as "botryomycosis hominis," attributing the lesion to a bacterial infection resembling botryomycosis in animals.^[42] This initial characterization reflected the era's emphasis on infectious etiologies, given the lesion's purulent, granulomatous appearance.^[43] By the early 20th century, the condition was recognized as non-infectious, with the term "granuloma pyogenicum" coined in 1904 by M.B. Hartzell to describe its pus-like exudate and granuloma-like histology, though this nomenclature proved misleading.^[44] In the 1920s, histopathological examinations further established its benign, reactive nature rather than an infectious process.^[2] Mid-20th century studies in the 1940s and 1950s, including reports by Frank and Blahd on nasal cases, clarified its vascular proliferation, shifting the understanding from an infectious granuloma to a reactive vascular lesion.^[45] During the 1970s and 1980s, histopathological analyses advanced the conceptual framework; in 1980, Mills et al. introduced the term "lobular capillary hemangioma" after examining 73 cases, highlighting its lobular vascular architecture and distinguishing it from true hemangiomas.^[19] Associations with pregnancy were documented during this period, noting increased incidence due to hormonal influences on vascular growth.^[2] From the late 20th century into the 21st, molecular studies beginning in the 1990s identified key angiogenic factors such as vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) as drivers of the lesion's pathogenesis, supporting the reactive hyperplasia model.^[46] The 2000s marked the emergence of laser therapies, such as pulsed dye and CO2 lasers, as effective alternatives to excision for superficial lesions.^[47] Post-2010 research has emphasized non-surgical management, with studies in the 2020s exploring VEGF inhibitors like subconjunctival bevacizumab for refractory cases, demonstrating regression without recurrence in select patients.^[48]

Terminology

The term "pyogenic granuloma" was coined in 1904 by M. B. Hartzell, reflecting a 19th-century misconception that the lesion resulted from infection by pus-forming (pyogenic) bacteria, although subsequent studies confirmed these growths are sterile and lack true granulomatous inflammation.^[39] The name persists in clinical practice due to its widespread recognition but is widely regarded as a misnomer, as the condition involves no bacterial involvement or pus formation.^[2] A more accurate histopathological designation, "lobular capillary hemangioma," emerged in the late 20th century—specifically introduced around 1980—to describe the characteristic lobular proliferation of capillary blood vessels without granulation tissue dominance.^[49] This shift emphasizes the benign vascular neoplasm's true etiology, avoiding confusion with infectious or inflammatory processes implied by "pyogenic granuloma."^[20] Dermatology pathology references and the World Health Organization's ICD-11 classification now prefer "lobular capillary hemangioma" for precision in describing this acquired vascular proliferation. However, "pyogenic granuloma" remains commonly used in clinical settings for its familiarity among practitioners.^[2] Additional synonyms include "granuloma pyogenicum," "granuloma gravidarum" (for pregnancy-associated variants), and "pregnancy tumor," the latter highlighting hormonal influences in gestation-related cases.^[12] Nomenclature variants distinguish superficial, often ulcerated forms from deeper subcutaneous types, sometimes termed "nonulcerated" due to their lack of surface erosion from being embedded in subcutaneous tissue.^[31] In the ICD-11, the condition is codified as 2F26 (lobular capillary haemangioma), falling under neoplasms of uncertain or unknown behavior of skin, superseding the ICD-10's L98.0 (pyogenic granuloma) for greater etiological accuracy.^[50]

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