By Gary M. White, MD
A pyogenic granuloma (PG) is a vascular growth common in both children and pregnant women. It seems to represent a reactive and hyperplastic condition, rather than a neoplasm. It usually develops at the site of skin injury and frequently bleeds.
The sudden appearance of a vascular, friable papule that bleeds easily on the finger, palm, sole, head, or neck is characteristic of a pyogenic granuloma. It is more common in pregnancy and in those patients on isotretinoin, especially in the periungual areas. Topical retinoid use has also induced PG. It may rarely occur after cryosurgery. It may occur in the periungual area, especially in the setting of retinoid or indinavir administration.
Multiple lesions may occur after burns [Pediatric Dermatology Vol. 32 No. 4 e175–e176, 2015] or lightning strike.
Is HPV-2 casually related? See above.
Multiple pyogenic granulomas may occur within or at the periphery of the scar of the treated primary lesion 1 to 4 weeks after its treatment. Lesions are often located on the back, especially the scapular region [Ped Derm 2016;33;97].
Local anesthesia followed by shave biopsy, curettage, and electrocautery is usually curative. If the lesion is not fully curetted, control of bleeding may be difficult and recurrence common. For lesions on a digit, a tourniquet may help during the procedure.
Aftercare should be minimal, allowing the area to scab. Patients and/or parents should always be told of the small risk of recurrence. If recurrence does occur, the same procedure may be tried again, or elliptical excision including a small amount of dermis may be done. The eruption of multiple lesions after treatment of a single one (satellitosis) occurs rarely. In the case of a giant PG with satellitosis, an oral steroid was successfully employed.
One, two, or three treatments with the pulsed dye laser was successful in 91% of children in one series.
Topical timolol, gel forming solution 2-3 times a day has been used with moderate success after 4-6 months of use in children Pediatr Dermatol. 2014 Mar-Apr;31(2):203-7. It may be considered in recurrent PG, satellitosis, periungual pseudopyogenic granuloma and PGs in areas where surgical intervention is difficult.
Various medications can induce paronychia and pseudopyogenic granuloma, the most notable being epidermal growth factor receptor inhibitors and isotretinoin. In one study, 9/10 patients with EGFI-associated PG had complete clearance after treatment with topical timolol 0.5% gel BID under occlusion for 1 month [JAMA Derm 2018;154;99].
Alternatively a compounded formulation of propranolol ointment 1% was used under hydrocolloid occlusive dressing for the treatment of pyogenic granulomas in 22 patients (mean age 7 years). Complete regression was observed in 13 patients (59%), in a mean time of 66 days [Pediatric Dermatology January 10, 2018].
Topical imiquimod nightly has had some success. Clobetasol under occlusion can be helpful.
Hidden underneath the crust in the scalp of a child.
PG in a pregnant woman.
The hands and feet are typical areas.
A patient on isotretinoin with a staph paronychia and a pyogenic granuloma.
Pyogenic granuloma x 2 in a patient on isotretinoin.
Pyogenic granuloma in a woman who constantly bit her nails (onychophagia)
Satellitosis after shave biopsy of primary lesion. Actas Dermo-Sifiliograficas 103;06;July 2012 - August 2012
Multiple PGs after a single PG was treated with pulsed-dye laser. Cutis. 2014 April;93(4):E4-E6
Eruptive disseminated PG after lightning strikes. Dermatology 2015;230:199–203
Multiple PGs after a burn. Pediatric Dermatology Vol. 32 No. 4 e175–e176, 2015
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