Ailesbury Clinic Cases
Treating Pyogenic Granuloma
A 37yo Irish male patient presented with a right pre-scapular growth for 3 weeks. The outgrowing mass was not painful but often bled while driving, after showering and sometimes spontaneously. The patient said it had started off as a spot and had rapidly enlarged into a ‘raspberry-like’ nodule, which bled into his shirt after he applied his seat-belt. It was continuing to get bigger and it was causing his wife some distress.
Examination revealed a smooth circular-shaped, pedunculated mass-like growth seen in region of the right scapula, measuring approximately 2.5 × 3.5 cm. This discrete nodular, erythematous enlargement was flattened against the skin where it was causing a small ulceration. On palpation, the mass was soft to firm in consistency and readily bled on probing. Based on the clinical findings, the case was provisionally diagnosed as pyogenic granuloma and the specimen after removal was sent for confirmatory histopathology.
An Ellman RF Surgitron was used both to incise and coagulate the lesion. This was done at a setting of 20 under 2% lignocaine with adrenaline.
Characteristic features pyogenic granuloma.
- Small red vascular lump that bleeds easily
- Often found at site of recent injury
- Usually seen on hands, arms, and face, but may develop in the mouth (most often in pregnant women)
Pyogenic granuloma is a relatively common benign mucocutaneous lesion. . It was originally described in 1897 by two French surgeons, Poncet and Dor. The term is a term is a misnomer because the lesion is unrelated to infection and is not granulomatous. It usually arises in response to various stimuli such as low-grade local irritation, traumatic injury or hormonal factors (1)
Mills, Cooper, and Fechner consider it as a capillary haemangioma of lobular subtype, which is the reason they are prone to bleeding. (2). Extra oral sites commonly involve the skin of face, neck, upper and lower extremities, and mucous membrane of nose and eyelids. Although pyogenic granuloma may appear at any age, 60% cases are observed between the ages of 10 and 40; incidence peaks during the third decade of life and women are twice as likely to be affected. It is more common in children and young adults. Being a non-neoplastic growth, excisional therapy is the treatment of choice but some alternative approaches such as cryosurgery, excision by Nd:YAG Laser, flash lamp pulsed dye laser, injection of corticosteroid or ethanol, and sodium tetradecyl sulfate sclerotherapy have been reported to be effective.(3) (4) There are few reports of treatment of mucosal pyogenic granulomas with radiosurgery. Differential diagnosis of pyogenic granuloma includes haemangioma, peripheral giant cell granuloma, peripheral ossifying fibroma and metastatic carcinoma, and amelanotic melanoma. (5)(6)
Although the conventional treatment for pyogenic granuloma is surgical excision, a recurrence rate of 16% has been reported. (7) There are also reports of the lesion being eliminated with electric scalpel or cryosurgery.(8) Other methods used by various workers include cauterization with silver nitrate, sclerotherapy, absolute ethanol injection dye, Nd:YAG and CO2laser, shave excision, and laser photocoagulation. The author achieved complete resolution of the lesion with radiosurgery without producing any complications. There was no bleeding scarring or recurrence.
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2. Shafer, Hine, Levy . In: Textbook of oral pathology. 5th ed. the Netherlands: Elsevier Publication; 2006. pp. 994–7.
3. J Cutan Aesthet Surg. 2011 May-Aug; 4 (2): 144–147. doi: 10.4103/0974-2077.85044 PMCID: PMC3183723 Laser: A Powerful Tool for Treatment of Pyogenic Granuloma Shalu Rai, Mandeep Kaur, and Puneet Bhatnagar
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13. Gonzales S, Vibhagool C, Falo LD, Jr, Momtaz KT, Grevelink J, Gonzalez E. Treatment of pyogenic granulomas with the 585nm pulsed dye laser. J Am Acad Dermatol. 1996;35:428–31. phosphatidyl choline and deoxycholate (50 mg/ml)