Overview

Pyogenic granuloma (PG) is an acquired, benign, vascular tumour of the skin & mucous membrane. It means a harmless overgrowth of small blood vessels in the skin. It is represented as a single, red or purple papule that proliferates rapidly within days and weeks, and is most frequently seen on the lips and fingers.

It cannot turn into cancer.

The main complications are bleeding and ulceration. The cause of pyogenic granuloma is unclear, but following minor trauma, low-grade irritation, hormonal effects, drug-induced reactions and poor oral hygiene are considered as the stimuli for PG. It leads to a reactive tumour, such as a lesion. Patients with pyogenic granuloma display inflammation in the gum region.

Pyogenic granuloma is most commonly seen in early childhood & assigned female at birth (AFAB) in their second decades of life, due to the hormonal effects.

Pyogenic granuloma will self-resolve sometimes, but to cure bleeding and ulceration, treatment is needed.

Surgical excision, curettage, cryotherapy, and laser ablation are the procedures used for the treatment of pyogenic granuloma. 

Epidemiology and demographics

Pyogenic granuloma can be seen in individuals of any age. Variation in the epidemiological pattern of pyogenic granuloma is seen. One study shows the incidence peaks in the second decade of life & is predominant in males. Another review showed the mucosal lesion of pyogenic granuloma is most prevalent² in assigned females at birth in their fourth decade of life. The ratio of assigned males at birth (AMAB) to assigned females at birth (AFAB) with PG is 1:1.2.

When considering both cutaneous & mucous lesions, AMAB are affected the same in their younger age through to their late twenties, compared to AFAB in their thirties or forties.

When considering the paediatric group, PG is seen in children aged six to eight, with a male sex predominance.³ Since increased vascularity is seen in younger age and children, the chance of occurrence of PG is very high.

Pregnancy is considered one of the causative factors for the development of pyogenic granuloma.¹ In pregnancy, PG is called a pregnancy tumour, usually occurring in the second and third trimesters. It is commonly seen on the buccal mucosa and the gingiva. Due to the raised levels of oestrogen and progesterone, an altered level of vascular response occurs to local irritants.⁶ Also, the use of oral contraceptive pills shows the incidence of PG in some studies.⁵

During pregnancy, puberty, and menopause, due to the hormonal effects, the chance of getting a PG is high.⁷

Pyogenic granuloma can occur anywhere in the body, but common anatomical sites are the face, mouth (gums), lips, tongue, nose, finger, and toes.

Pathophysiology

Histological Features:

Histologically, pyogenic granuloma is divided into: 

• Lobular capillary hemangioma (LCH)
• Non-lobular capillary hemangioma (non-LCH)

Early phase: it shows diffuse endothelial cells with varying capillaries.

Capillary phase: In LCH, lobular aggregates of blood vessels are seen. Only granulation tissue is seen in non-LCH, no properly arranged blood vessels or associated structures.
Involutionary phase: Fibrosis of connective tissue in the stages of healing. It mainly consists of granulation tissues, fibroblasts, and collagen.

Involvement of Growth Factors and Cytokines

Clinical presentation

Clinically, pyogenic granuloma presents itself as a small fleshy bump protruding through the skin or mucous membranes. It shines and has a minced meat appearance. It will grow rapidly within weeks to months, from a millimetre to a centimetre.

It may appear in pink, red, or reddish brown and purple colours, and it has a white collar-like layer at the bottom of the lesion.

When it grows, it can be directly attached to the skin (sessile) or may be attached to the skin with a stalk (pedunculated).

During the initial phase of growth, the surface of the lesion is smooth and soft. Later, when it matures, the surface will turn rough and crusty. As it becomes delicate, it will ooze and break, bleed easily, and ulceration of the lesion will occur.

Pyogenic granuloma is not an infectious type; it will not spread. The appearance of one lesion at a time is common, but sometimes several appear at once.⁸

Differential diagnosis

Based on history & examination, pyogenic granuloma can be easily diagnosed, but certain other lesions may show resemblance to PG. These are:

• Squamous cell carcinoma
• Basal cell carcinoma
• Angiosarcoma
• Amelanotic melanoma
• Hemangioma
• Warts
• Granulation tissue from a minor trauma or scratching
• Kaposi sarcoma in immunosuppressed individuals

 Diagnostic approach

• Pyogenic granuloma is easily diagnosed during clinical examination. If there are any concerns or doubts, the lesion is taken for histology, and then surgical excision of the lesion is done
• Ask the patient about the history of minor trauma or irritation, like cuts, insect bites, nail biting, or even the aggressive brushing of the teeth. These will cause the entry of microbes into the tissue and elicit an inflammatory reaction, the release of vascular endothelial factors, and then the healing phase starts, leading to the formation of new blood vessels. This reaction shows the formation of a granuloma
• Enquire whether the patient is pregnant or not
• Review of all their medications 
• Take the tissue, send it for biopsy, and examine it under a microscope⁹ 

Management and treatment

• Conservative approaches

The usual treatment is excision, which has the lowest recurrence rate. 

• Surgical approaches

 Based on location, size and patient wishes:

• Curettage: it scrapes the lesion out, making the skin inside hot by using cautery
• Electrocautery: reduces bleeding, facilitates anticoagulation. The patient can tolerate these procedures well
• Radiosurgery
• Cryosurgery - to freeze the lesion away
• Sclerotherapy is used
• Diode lasers of 808 to 980 nm, CO2 laser, and erbium-YAG are also used to destroy the abnormal tissues
• In children, topical or oral medications like β-blockers, timolol, and propranolol are used¹¹
• Steroid injection into the skin⁹
• Chemicals like phenol, silver nitrate, and trichloroacetic acid are used on the skin to shrink pyogenic granuloma
• Removal of triggering agents like any medications, sharp things, dental calculus, plaque, foreign bodies, defective filling of the tooth,¹² piercings, and oral-related problems that irritate the mouth, and maintaining good oral hygiene 

Prognosis and recurrence

The lesion will not cause cancer or shorten your lifespan.

The lesion is rapidly growing, makes an ulceration, and sometimes it bleeds, hence it will not regress spontaneously. Partial resection or curettage will cause the incomplete removal of lesion, so recurrence occurs. In pregnant women, the lesion will regress once they deliver the baby.

To avoid recurrence in future, complete resection or complete surgical excision is preferred.¹⁰

The pyogenic granuloma in the gingival (gum) region will show a higher recurrence rate than other oral mucosal PGs.
The recurrent lesion should be treated wisely, giving importance to the removal of etiologic factors, and also not causing any detrimental effects to the underlying hard and soft tissues.

Histologically recurrent lesion shows hyperplastic epithelium, dense inflammatory cell infiltrate in the connective tissue.¹²

Patient education & preventive measures

Patients may need reassurance as they are more worried about the sinister condition of the lesion in the future. The patient should be advised not to prick or scratch the lesion to avoid possible secondary infection. They may need to cover the lesion with bandages.

The physician should explain the best treatment modalities for the successful removal of the lesion, with no recurrence chance later.

FAQs

What causes pyogenic granuloma?

It can occur at any age, but is mostly seen in young adults and children, and also in pregnancy. Minor injury is the most common reason. Other reasons are medications like retinoids (used for acne) and oral contraceptive pills. PG is not an infectious disease and will not spread to other people.

Is there any risk of pyogenic granuloma coming back?

Up to 15% recur just soon after the treatment, it's necessary to follow advice from the concerned physician and follow up.

What happens if I don't treat pyogenic granuloma?

If you don’t undergo treatment, it will bleed and ulceration will happen. Since the surface of the lump is very thin, you have to cover the surface of growth with a band-aid to prevent bleeding, and also to cure the pain. Small pyogenic granulomas will go away on their own without any treatment. Pyogenic granuloma associated with pregnancy and those that appear while taking medication will shrink over time.

Summary

Pyogenic granuloma is a well-known oral lesion; the name pyogenic granuloma is a misnomer because it does not contain any pus or does not represent any granulation histologically.

Gingiva is the most common site of the lesion intraorally. Lips, tongue, buccal mucosa, and palate are the other sites, since the trauma is most common in such sites.

Pyogenic granuloma occurs as a result of tissue response to a minor trauma or local irritants that allow the entry of microorganisms into the vascular endothelium, triggering an inflammatory cascade that promotes angiogenesis and granulation tissue formation.

The role of trauma in pyogenic granuloma not only helps in diagnosis, but it also makes the patient aware and prevents recurrence.