What Is Pyogenic Granuloma?

Overview

Have you got a strange new growth on your skin that's worrying you? It could be that the growth is a pyogenic granuloma (PG). In this article, we will explain to you exactly what that is and what it could mean. It is important to obtain all the necessary information so that you can make a proper and informed decision about the next steps. 

What is pyogenic granuloma? 

A PG is a benign (non-cancerous) tumour which can appear on your skin or even inside your mouth, eyes or nose. This tumour consists of abnormally developed blood vessels and it is also known as lobular capillary hemangioma or granuloma gravidarum. Fortunately, this type of tumour is not known to progress to cancer and is therefore mostly harmless.¹

Causes and risk factors

PG are often seen in children and young adults as well as during pregnancy with an overall slight predominance seen in individuals assigned female at birth (AFAB).² The exact cause of PG is unknown, but there are certain factors which have been linked to them, such as: 

• Chronic irritation of the skin or minor trauma are thought to be common causes of PG. minor injuries or piercings in the mouth or nose can also account for the formation of PG’s 
• PGs can also occur due to hormone fluctuations in the body such as during pregnancy and with the use of oral contraceptive pills
• Infections with staphylococcus aureus can also cause PGs, as well as poor oral hygiene
• Certain medications may also trigger PG formation such as medications used in the treatment of HIV infections (protease inhibitors), retinoids taken by mouth, immunosuppressive drugs and some cancer treatment medications³

Clinical presentation

PG can occur anywhere in the body that is covered either by skin or mucous membrane. They are most commonly found on the face, fingers, toes, gums, tongue, lips or nose.⁴ During pregnancy, they are most commonly seen inside the mouth. PGs are not commonly found on the genitals, the gastrointestinal tract and in the trachea but if they do occur in the gastrointestinal tract, they can lead to anaemia due to the bleeding which occurs with them.

PG are made up of small blood vessels and capillaries, so they appear as a red, pink or purple coloured bump on your skin. Since they are made up of capillaries, they have a tendency to bleed easily and quite often, profusely. Despite this bleeding, PGs are not known to be painful.  

They start off small and smooth but can grow rapidly, up to half an inch. As they grow they can develop a white-ish coloured scaly base and a bumpy surface, or they might even ulcerate. They can also become pedunculated, which means they can develop a stalk and hang off of that from your skin in a “mushroom-like” appearance. However, it is also possible that they stay attached to your skin and do not develop a stalk and this state is known as sessile. In spite of their rapid growth, PGs rarely grow more than 2.5cm in size.⁵

PG are not considered to be hereditary or contagious and whilst they are usually found as a single entity, there can be several found at once too. 

Diagnosis

PGs are mostly diagnosed clinically which means that your doctor might diagnose you based on your signs and symptoms alone rather than any laboratory tests.

Your doctor might ask you about any recent injuries or trauma you may have had in that region and they might also inquire about any medications you might be taking or if you could be pregnant. Your doctor will also examine the growth, possibly with the help of a magnifying glass known as a dermatoscope.

Sometimes, your doctor might recommend removing the PG under local anaesthesia and sending it to the laboratory for a biopsy, just to be certain that the PG is not anything more sinister. This is because, on rare occasions, a PG might resemble other more serious conditions such as skin cancer or Kaposi's sarcoma.¹

Treatment options

The treatment of PG involves the removal of the bump or removing the factors which might be triggering it such as any medication, chronic irritation, piercing or improving dental hygiene. PGs that occur due to pregnancy will usually resolve themselves after the pregnancy. There are several options to remove PGs which can either involve topical mediation or some simple procedures.¹

Treatment with medication

You and your doctor can discuss which treatment option will be most suitable for you. Some examples of topical medications are: 

• Imiquimod (usually 5%). This is applied in a cream form and it is used as an immunotherapy which functions by triggering the patient's immune system. It has proved to be very effective, cost-effective and safe with minimum side effects and thus, it can even be used on children⁶ 
• Other creams which contain trichloroacetic acid, silver nitrate or phenol. Creams which contain silver nitrate cause chemical cauterisation (chemically burning the abnormal tissue) of the PG which can reduce the bleeding and help to get rid of the growth. Phenol is a weak acid that acts as a sclerosing (inflammation-inducing) agent by causing local inflammation and swelling which can reduce the bleeding and help to cure the PG
• Timolol is a type of beta-blocker which can be used in the form of eye drops if the PG occurs in the eye. It has proven to be effective as well as safe⁷ 
• Another option for conservative treatment is injecting steroids directly into the lesion. An example of the steroid used for this procedure is a corticosteroid such as triamcinolone acetonide. However, some people might prefer to avoid injections and opt for topical medications instead

Treatment with surgical procedures

There are also a number of procedures available which can be effective for the removal of PGs. 

• Curettage and cauterisation: This is conducted under local anaesthesia which means that your doctor will numb the affected area before the procedure. Then, the PG is removed by curettage (cleaning or scraping, surgically) and then the blood vessels left behind are cauterised (burnt off) to prevent them from bleeding 
• Cryotherapy: In this method of removal, freezing cold is used to remove the abnormal tissue and this is usually done with liquid nitrogen. It has proven to be an effective and simple procedure for PG removal⁸ 
• Laser treatment: There are different types of lasers which are available and used to remove PG from the skin. They do require follow-up treatments but they are generally painless, well-tolerated and safe 
• Surgical excision: at times, your doctor might recommend surgical excision of the PG. This is a simple, short surgery in which the PG is removed and sometimes sent for further testing

Topical medication is the preferred method of treatment for children as it avoids more invasive procedures which can be distressing for children. However, topical medication does require strict compliance. Treatments such as steroid injections and lasers are the preferred method for multiple PGs or particularly large ones. 

There is a chance of recurrence after the PG has been treated, and the treatment method with the lowest rate of recurrence is surgical excision.⁴ 

Complications and prognosis

The prognosis for PG is good and the pregnancy-associated PGs can even go away on their own without treatment. There is no risk for cancer but they can recur and cause bleeding and infections.¹ Call your doctor if you notice any signs of infection such as pain, redness, swelling or pus. 

Prevention 

A large part of preventing PG is avoiding the triggers that can cause them. This would include avoiding any medication that can cause PG, preventing any chronic trauma or irritation to the skin surfaces and having good oral hygiene.¹ Any piercings in the mouth also need to be well taken care of, in order to avoid further irritation in the mouth. 

Summary

PGs are harmless growths which can occur on your skin, and there is no risk of their progression to cancer. They are formed through the abnormal development of blood vessels and thus, they have a tendency to bleed when they are irritated. They appear as small, reddish or purple-coloured bumps and they can be found anywhere on your skin or mucous membranes. They tend to grow rapidly. 

There are several medications which can cause PG as well as infections, poor oral hygiene and any chronic irritation to the skin, such as piercings. PGs are also common in pregnancy due to the associated hormone fluctuations. Your doctor might be able to diagnose you just based on your symptoms and looking at the bump. 

There are several treatment options available. Topical medications are a good option for children and for those who want to avoid any procedures. Additionally, these medications are safe and effective. Some procedures are also available, that can involve scraping off the bump, lasers or surgery, which are all simple and effective procedures. 

PGs have a tendency to get infected but generally, they carry a good prognosis. PGs can recur in the body and it is important to avoid any potential triggers that might be causing them.