Introduction

Pyogenic granuloma, also known as lobular capillary hemangioma, is a type of tumour found on the skin and mucous membranes.¹ It is essentially a non-cancerous, benign growth that occurs within the blood vessels. The clinical presentation appears as red and raised bumps on the surface of the skin, specifically on the hands and arms. The most common areas where the lesions can be seen are within the oral cavity, and they are specifically seen to form during pregnancy, in the second to third trimester, due to hormonal changes in the body.² The main symptoms of pyogenic granuloma involve rapid growth, irritation and the lesion bleeding easily. They are usually painless lesions; however, they do require medical attention as irritation and bleeding can be very uncomfortable and affect an individual’s daily life. Nevertheless, understanding these common symptoms is crucial in making an accurate diagnosis and treating pyogenic granuloma effectively. 

Causes of pyogenic granuloma 

Several factors may contribute to the development of pyogenic granulomas, including:

• Hormonal changes are very commonly associated with pyogenic granulomas, making pregnancy and taking the contraceptive pill common factors
• Trauma or minor injuries, such as piercings in the nose and ears
• Specific medications such as oral retinoids, targeted cancer therapies, and immunosuppressive drugs
• Infections in the body make you more susceptible to forming lesions, especially in the mouth, where poor dental hygiene can contribute to lesion formation

Although the prevalence of pyogenic granuloma is rare, most pyogenic granulomas occur in children and young, assigned male at birth. However, they can still develop at any age. Hormonal-related disorders could also be an underlying cause of pyogenic granulomas, with fluctuating estrogen and progesterone levels in the body causing vascular proliferation. Nevertheless, pre-existing skin lesions and vascular trauma increase the risk of developing pyogenic granuloma. The lesion's rapid development and growth are a reflection of an imbalance of angiogenesis and tissue repair, which leads to rapid vascular proliferation. 

Symptoms- bleeding

One of the main symptoms of pyogenic granulomas is bleeding, which can be spontaneous or occur due to trauma. The capillaries in the lesions are very thin blood vessels which are fragile and prone to breakage, leading to bleeding. The common triggers of bleeding involve: touching the lesion, abrasives or chemical products near the lesion, and clothing on the surface of the lesion. Although bleeding can be triggered easily, a minor injury or trauma to the area of the lesion puts it at high risk for bursting and continuous bleeding. The frequency and the way the lesion bleeds depend on the location of the lesion. If there is a persistent episode of bleeding, then this must be seen by a medical professional to prevent further health complications. 

Symptoms- rapid growth

Pyogenic granulomas show many common symptoms, including rapid growth. The speed of growth varies from weeks to a few months. The size of pyogenic granulomas varies depending on the location; however, it is commonly a few millimetres to a few centimetres in diameter.³ The age of the growth is associated with the colour of the lesion; newly formed pyogenic granulomas are bright red due to a large number of capillaries, whereas older lesions are more pink in colour with fewer blood vessels.⁴ The lesions usually appear dome-shaped, flat and have firm or smooth surfaces. For example, in oral cavities, if the lesion has a firm surface, this indicates that it is old due to the collagen fibres.⁵ In this way, a physical examination can be useful to identify the growth pattern of the lesions and explore the symptoms individuals experience. If there is abnormal growth of the pyogenic granuloma, this should be checked out by a medical professional, as it may indicate other underlying health conditions. 

Symptoms- irritation

Pyogenic granulomas can become physically irritated and inflamed due to many causes. Most frequently, granulomas on the surface of the skin rub against clothing, which causes discomfort. Touching the lesion can cause inflammation due to bacterial residue on the hands, which can also contribute to the infection risk if the lesion is bleeding. The general symptoms of pyogenic granuloma irritation are; 

• Pain
• Redness
• Swelling 
• Inflammation 

Pyogenic granulomas become irritated in various ways depending on the location. For example, in the oral cavity and mucous membranes, irritation occurs through daily life interactions such as speaking, eating, or swallowing. Frequent irritation causes inflammation, which can then lead to an infection, and if left untreated, this can form into serious life life-threatening conditions such as sepsis. Irritation can also be a side effect of laser treatment for pyogenic granulomas (discussed in more detail later in the article). To manage irritation, protect the affected area as much as possible, and if irritation becomes severe or is causing distress, please contact a medical professional.

Diagnosis

The diagnosis of pyogenic granuloma includes a clinical examination where a medical professional has to take a closer look at the lesion. A dermatoscope, which is a specialised medical magnifying glass, is used in physical examinations to inspect the skin lesions in detail.   

Although pyogenic granuloma has specific characteristics, it resembles vascular lesions such as warts, hemangiomas and glomus tumours.⁶ Therefore, a biopsy can be taken for histopathological examination to confirm the diagnosis. 

Microscopic investigation also helps distinguish whether the lesions are cancerous or not by viewing the tissue taken from the biopsy. These steps are crucial for differential diagnosis as the clinical presentation of pyogenic granulomas is very similar to other types of benign growths. Specifically, cherry angiomas, which are very similar in clinical presentation and are also a type of benign lesion, however, they grow slowly in comparison to pyogenic granuloma. There are also malignant lesions, such as squamous cell carcinoma, that have very similar characteristics to pyogenic granuloma; therefore, a histological examination is the best option to distinguish between them.  

Treatment options

There are a few options in terms of treating pyogenic granuloma; medical treatments, surgical interventions, and physical modalities are all options. 

Topical treatments, such as imiquimod cream, can be applied to smaller lesions, and timolol is used for paediatric patients where surgery is not an option. A study carried out on timolol showed that four out of ten people showed improvement in lesions without any side effects, making timolol safe and effective to use.⁷

On the other hand, surgical removal of pyogenic granulomas is used widely, particularly for lesions larger in size and that carry a risk of bleeding and irritation. For example, pregnancy-related pyogenic granulomas have a high recurrence rate after topical medication; therefore, surgical removal can be a better option. The complete removal of the lesion is carried out via a surgical excision under local anaesthesia. There is a lower recurrence rate and no bleeding symptoms with this procedure.⁸

Laser treatment is another option used to treat pyogenic granuloma that presents with smaller lesions. Pulsed dye lasers (PDL), CO₂ lasers and Nd:YAG lasers are the types of lasers used to target the blood vessels and the vascular tissue within the lesion and destroy it. The Nd:YAG laser, in particular, is used widely as it is known to target deep tissues and is powerful enough to be used on large and thicker lesions; therefore, fewer treatments are needed to successfully remove the lesion. A non-comparative study portrayed a success rate of 74% after one session of Nd:YAG laser therapy.⁹ Overall, laser treatment is a successful treatment option which is minimally invasive and has a quick recovery rate; however, there are disadvantages, including accessing the right laser type for the specific lesion and high cost rates. 

Summary 

To summarise, the main symptoms of pyogenic granuloma are rapid growth, bleeding, and irritation. These symptoms are covered in depth in this article and are all hallmarks of pyogenic granuloma. Each symptom presents in different ways depending on the age, medical history and general health of the affected individual. The type and nature of symptoms can also be important information for medical professionals, as it can help facilitate more accurate and swift diagnosis and treatment. The prognosis for pyogenic granuloma is considered good when the suitable treatment is applied; however, in some cases, recurrence of the lesions is seen.