Definition of Cutaneous Pyogenic Granuloma

Pyogenic Granuloma is a common, benign vascular proliferation which can be found on the skin or subcutaneous tissue.¹ They appear as bright red, rapidly growing lumps. Over the course of a week or even a month, it stops and usually doesn’t get bigger than 1 cm. Sometimes, if there is slight pressure applied or any sort of contact, these pyogenic granulomas can bleed. Despite their abnormality compared to normal skin tissue, they are harmless and non-cancerous.

Appearance of Pyogenic Granuloma

Other than being bright red lumps protruding out of the skin, another key aspect of their appearance is their texture. They possess a smooth or bumpy texture, and if they've bled recently, they may also become crusty due to the dried blood.³ These lumps sometimes have a pus-like material surrounding them, which is a white/yellow colour. In terms of where they are on the body, they most commonly form on the fingers, face, and scalp. They may also appear pink, brown, or purple. They have a smooth or bumpy texture, but they can also become crusty if it has recently bled. A common location for this condition is the fingers, face, and scalp. They can also be birthmarks, and in pregnant women, they can sometimes appear on the gums too.

Epidemiology and Risk Factors

Pyogenic granuloma is more prevalent within children and young adults, and within this demographic, there appears to be no gender bias for the condition, and this may closely link with the fact that the skin condition can be caused by minor trauma accounts which children more frequently experience.⁷ Triggers, such as nasal piercings, have been reported to have an association with intranasal pyogenic granuloma. In the older demographic, there is a gender bias towards women due to the association with pregnancy and oral contraceptives. Across all ages, there is no gender bias. During pregnancy and oral contraceptives, there is a change in the hormonal composition within the body, and this can trigger the formation of pyogenic granuloma. Poor dental hygiene is commonly associated with the condition. On top of this, oral retinoids and other medications, including cancer therapies and immunosuppression, can cause pyogenic granuloma.

The importance of accurate diagnosis of Pyogenic Granuloma

It is important that any concern you have is addressed to a healthcare professional for accurate diagnosis to check if any skin issue is a pyogenic granuloma and not mistaken for a serious condition.² Pyogenic granuloma can be mistaken for other skin conditions, including amelanotic melanoma, Kaposi sarcoma, and bacillary angiomatosis. Amelanotic melanoma is a form of melanoma (skin cancer) where the malignant cells carry little pigment.⁴ Kaposi sarcoma is a disease of endothelial cells of blood vessels and the lymphatic system.

As well as appearing on the skin, this condition can also be present in internal organs, such as the lungs, and it can cause great discomfort for the individual, such as difficulty breathing.⁵ Lastly, bacillary angiomatosis is a cutaneous and systemic bacterial infection caused by the bacteria Bartonella quintana and Bartonella henselae. It can cause the individual to develop uncomfortable symptoms, including high fever, vomiting, and poor appetite.⁶ These differential diagnoses share many aesthetic features; however, they are much more severe and require medical attention, unlike the pyogenic granuloma, which is harmless.

How Pyogenic Granuloma is Diagnosed

As pyogenic granuloma has many shared features with other skin lesions, it is crucial that the diagnosis of it is accurate. To diagnose this condition, the healthcare provider may do the following:

• Ask about any recent injury or irritation – pyogenic granuloma can be triggered by any trauma or damage to the skin, so if the patient had a recent injury, it could result in the skin lesion being inspected
• Examine the patients’ skin or mucous membrane – despite them sharing lots of features, appearance-wise, examining the appearance can help to rule out lots of other skin conditions. The healthcare provider will inspect the colour, shape, size, and location of the lesion
• Ask about being (possibly) pregnant – pregnant women release hormones which are correlated with the formation of this condition
• Ask about current medication – some medications, such as antibiotics, can affect blood vessel growth

More often than not, the health provider will be able to make a well-made decision based on the information provided above; however, if there is still some uncertainty, some may opt for a biopsy too.⁷ A biopsy is a simple medical procedure which involves extracting a small amount of the body tissue and examining it under the microscope.

Treatment Options for Pyogenic Granuloma

In terms of treatment options, there is a wide variety of them, which include treating the underlying cause of the condition, topical treatment, and procedural treatment.

Factors such as poor hygiene or piercing can trigger the condition, so considering oral hygiene or potential oral treatments to help the overall health of the patient can help with pyogenic granuloma. As well as that, if the condition is near a piercing, it may be a strong indicator that it is a trigger, so removal of any adjacent piercings can help. If there is a potential medication being taken which may be causing it, it needs to be stopped or replaced with an alternative if feasible.

There is a wide variety of topical treatments. The most common ones include:

• Imiquimod cream 5% – Stimulates the release of cytokines to help fight off infections
• Timolol gel 0.5% and other topical (or oral) beta-blockers – Work by blocking receptors of the blood vessels and narrowing them to stop blood flow within the lesion
• Intralesional steroid injection – Injection of steroid directly into the lesion to help manage inflammation
• Cryotherapy – A minimally invasive procedure that utilises extreme cold temperatures to remove abnormal tissues; it is used frequently to remove things such as skin tags
• Table salt – A simple at-home treatment option. Petroleum jelly is applied to the periphery of the lesion, and then table salt is applied to the whole surface of the lesion. Works by drawing out the fluid from the lesion, diminishing its appearance on the skin and eventually healing away¹⁵

Sometimes, if topical treatments aren’t working or patients want the lesion removed for aesthetic purposes, for example, they may prefer to have a procedural treatment for instant removal. Procedural treatment for pyogenic granuloma includes:

• Curettage and cautery – local anaesthetic is applied to the surrounding area, and then the protruding region is scraped off with a knife. Heat is then applied to the area to remove any residual tissue¹²
• Surgical excision – the pyogenic granuloma is cut out, and then, depending on the depth of the incision, it is often sutured back together¹³
• Vascular and ablative lasers – use high energy sources to remove the outer layer of the skin, and the heat of the layer also stimulates new tissue growth under the skin¹⁴

Conclusion

In conclusion, pyogenic granuloma is a harmless vascular proliferation, however, its appearance is shared with many other skin conditions, some of which require great care and attention. For this reason, diagnosis is very important. Diagnosing the condition can include building a rapport with the patient, which details their medication, past injuries, or any chance of pregnancy, as these factors can lead to the development of the condition. If more certainty is needed, a biopsy may also be performed, and the tissue of the lesion itself is examined under a microscope for a definitive answer on what it is.

Despite their harmlessness, people may want to treat and remove this for aesthetic purposes or if it’s becoming an inconvenience to them, for example, if it is in the nasal cavity and affecting breathing. There are many different treatment options, for example, there are topical treatments, including different ointments or cryotherapy. The different ointments tackle the issue at a microscopic, biological level, whereas cryotherapy removes the abnormal tissue. There are also procedural treatments which are more invasive, however, they are quick and easy procedures to remove the lesion. As well as this, doctors may also advise patients to have a better hygiene routine if it is a hygiene-related cause, or to remove any piercings around the lesion.