Pyogenic granuloma

Introduction

• Benign proliferation of capillary blood vessels of the skin and oral cavity.
• Misnomer; it is a lobular capillary hemangioma, not an infection.
• Synonyms: granuloma gravidarum, pregnancy tumor (during pregnancy).

Demographics

• Common in children (~6 years) and teenagers/young adults.
• Overall male predominance (3:2), except for oral lesions (linked to pregnancy, oral contraceptive use).
• No racial predilection.

Causes

• Trauma (recent minor trauma, chronic minor irritation in oral cavity, nasal piercings).
• Hormonal influences (oral contraceptives, pregnancy).
• Medications (oral retinoids, protease inhibitors, targeted cancer therapies, immunosuppression).
• Infection (Staphylococcus aureus, poor dental hygiene, no viral evidence).

Clinical Features

• Skin: painless red fleshy nodule, 5-10mm, grows rapidly, easily bleeds.
• Oral mucosa: red papules on lip/gums, ulcerated surface, bleeds easily, becomes paler pink over time.
• Common sites: fingers, face, conjunctiva, nasal mucosa.
• Solitary or multiple nodules.

Dermoscopy Features

• Distinct keratinized border (white collarette).
• Vascular structures, red homogeneous areas, no clear lacunar pattern.
• White linear ‘rail lines’.

Complications

• Frequent bleeding, potential anemia

Diagnosis

• Clinical diagnosis.
• Histology: lobular capillary arrangement in the dermis, thinned/ulcerated epidermis, inflammatory changes, secondary hemorrhage.
• Two histological types in the oral cavity: lobular capillary hemangioma and granulation tissue-like vascular proliferation.

Differential Diagnoses

• Cutaneous: amelanotic melanoma, Kaposi sarcoma, bacillary angiomatosis.
• Oral cavity: peripheral giant cell granuloma, peripheral ossifying fibroma.
• Histology: cherry angioma, bacillary angiomatosis.

Treatment

• General: address/remove triggering factors (drug cessation, oral hygiene, dental treatment, remove piercings).
• Topical: Imiquimod cream 5%, Timolol gel 0.5%, intralesional steroid injection, cryotherapy.
• Procedural: curettage and cautery, surgical excision, vascular/ablative lasers.

Outcome

• Rare spontaneous resolution (except post-partum).
• Recurrence common, especially in gingival lesions with inadequate treatment or persistent factors.