Overview

Poncet and Dor were the first to describe Pyogenic granuloma (PG) in 1897 when it was found in four patients having “vascular tumours” on their fingers. They named it “Botrichomycosis hominis”. Later in the year, 1904 Hartzell came up with the term “pyogenic granuloma”.¹ There is an overall male predominance over females (3:2) except for oral lesions as the females are related more to pregnancy and usage of oral contraceptives.² There is no racial predilection evident. Oral PG prevails within the age group of 4.5 to 93 years, and it shows a marked rise in its occurrence in the second and fifth decades in females compared to males. This disease has been mostly seen to occur in males less than 18 years and females aged between 18–39 years, with equal gender distribution in older patients. Although the gingiva in the oral cavity accounts for 75% of the sites of occurrence PG may occur in other areas such as the tongue, lips, buccal mucosa (towards the cheek), hard palate, and peri-implant mucosa (the region around the implant), and it affects the maxilla (upper jaw) more than the mandible (lower jaw), the anterior (front) region more than the posterior (back) region, with the buccal surfaces more affected than the lingual (towards the tongue) surfaces. The floor of the mouth is an uncommon site of occurrence of PG.^1,3

Definition

Pyogenic granuloma, also called granuloma pyogenicum, is a common, acquired, benign (non-malignant) vascular tumour that arises in tissues such as the skin and mucous membranes. Scientifically, it is termed lobular capillary hemangioma. In the past, pyogenic granulomas were thought to be an exaggerated granulomatous reaction to an infection or purulent (related to pus) in nature, thus the terms ‘pyogenic granuloma’ and ‘granuloma pyogenicum’ were coined. However, the term pyogenic granuloma is a misnomer that may initially be confused as the lesion neither shows any oozing of pus nor is granulomatous.³

What does it look like?

PG of the skin looks like a red fleshy nodule, typically 5-10mm in diameter, with rapid growth for over a few weeks. The lesion has a smooth surface at its onset, but it can ulcerate, and become crusty or verrucous later on. The face and fingers are the most commonly affected sites. The conjunctiva of the eyes and nasal mucosa are less affected sites. Pyogenic granuloma easily bleeds with minor trauma. Oral mucosal pyogenic granulomas typically develop on the lip and gums (gingiva) as pedunculated (lesion with a stem attached to the base) or sessile (firmly attached to the base without any stem) slow-growing painless red papules ranging in size from a few millimetres to several centimetres. Eventually, the lesion obtains a paler pink colour.²

Causes of pyogenic granuloma

Hormonal changes

PG can occur with the usage of oral contraceptives and in 5% of pregnancies due to the drastic hormonal upheaval taking place in the former two cases.² It is termed granuloma gravidarum, granuloma of pregnancy, or epulis gravidarum when it occurs in the oral cavity of a pregnant woman in the second or third trimester of her pregnancy.³ Hormones like estrogen and progesterone, especially during puberty and pregnancy, play an important role in the development of the lesion in girls/women. The lesion seems to occur mostly on the buccal mucosa and gingiva of the oral cavity.⁴ 

Infection

Staphylococcus and Streptococcus species are the causative agents in this condition. Human herpesvirus 8 has also been assumed to play a role. Bacterial strains present within these lesions may not be the causative agents but rather the contaminants from the superficial surrounding infected skin. However, Staphylococcus and Streptococcus may cause oral PG because they can grow into mucoid colonies. There may be secondary contamination of the surface of the pyogenic granuloma that leads to ulceration, infection, and a crusted appearance. Pus formation is rarely seen with this lesion.⁴ Infection due to dental calculus, dental biofilm, periodontitis, and food impaction may give rise to PG in the oral cavity.¹ The lesion is closely associated with poor oral hygiene. There is no relationship with any virus-related infections.²

Trauma

PG is grouped under reactive oral lesions that develop in response to irritation /trauma and where there is an increase in the inflammatory response of the tissue. Irritation may take place due to exfoliation of primary teeth, injury by a primary tooth, or eruption of permanent teeth. Defective restorations in the mouth can also cause trauma in the area of the lesion. Occlusal interference, food impaction, and trauma from toothbrushing can also give rise to PG in the oral cavity.¹ Recent minor trauma accounts for 7% of presentations and, chronic minor irritation is thought to be a common trigger in the oral cavity. Intranasal (within the nose) PG may occur due to nasal piercings.²

FAQs

Are pyogenic granulomas cancerous?⁵

No. Pyogenic granulomas are non-cancerous, non-contagious, non-hereditary, and painless overgrowth of tiny blood vessels. Pain may be associated with bleeding.

Can PG be treated?⁵

A few of them may lose color and whither off with time but most of them require either application of medications or surgery. 

Is there a chance of recurrence of PG?⁵

There is a chance of 15% of PG recurrence. In such cases, the area is cut out and the wound is closed with stitches. 

What are the preventive measures for the occurrence of PG?²

• Stoppage of triggering drug
• Maintenance of oral hygiene
• Treatment of trauma /injury due to teeth
• Removal of adjacent piercings

Surgeries for removal of PG?²

• Curretage and cautery
• Surgical excision
• Vascular and ablative lasers.

Summary

Medications such as oral retinoids, protease inhibitors (used in the treatment of HIV/AIDS), targeted cancer therapies, and immunosuppression precipitate the development of multiple pyogenic granulomas, though the mechanism is not yet clear. You may seek help because of the pain and bleeding associated with the lesion. You should abstain from scratching or picking at the lesion and must take some precautions to avoid trauma or secondary infection. PGs are friable lesions that may lead to undue anxiety because of the lesions' unfamiliarity and their treatment outcome. Because of their abrupt onset, you may opt for urgent care, primary care, visit pediatric (for children) clinics, dermatology (skin) clinics, and podiatry (leg and foot) clinics, or sometimes even seek an oncologist (cancer specialist) or surgeon. When these lesions are excised, partially or wholly, the specimen is sent for histopathologic assessment to differentiate it from other similar lesions or conditions.