Pediatric Pyogenic Granuloma

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Pyogenic granulomas (PGs) are benign vascular lesions that occur most commonly on the acral skin of children. [1, 2] The term pyogenic granuloma is a misnomer. Originally, these lesions were thought to be caused by bacterial infection; however, the etiology has not been determined. The histopathologic appearance is fairly characteristic; the lesion is, in fact, a lobular capillary hemangioma. [3]

Recognition of pyogenic granuloma as a clinically polypoid or exophytic circumscribed lesion is of importance to the clinician and pathologist because this feature distinguishes pyogenic granulomas from most malignant vascular tumors. Although pyogenic granulomas may be multiple (especially on the skin) and necrosis is common, invasion of adjacent structures is not observed. The lesions grow rapidly and are extremely vascular, frequently bleeding either spontaneously or after minor trauma. [4] They are usually easily treated with surgical removal but may recur.

Uncommon variants include pyogenic granuloma with satellitosis, [5, 6, 7] intravenous pyogenic granulomas, [8] subcutaneous pyogenic granulomas, [9, 10] and eruptive pyogenic granulomas. [11, 12, 13] Satellite lesions of smaller pyogenic granulomas may develop at the same time as the primary lesion or may occur after attempted treatment of the primary lesion. See the images below.

Although most patients (74.2%) do not have a history of trauma or predisposing dermatologic conditions, in many cases, a history of recent trauma at the site is present. Large numbers of lesions may occur following damage to diffuse areas skin by burns or other trauma. [14, 15] A nitric oxide synthase–dependent mechanism is thought to contribute to angiogenesis and the rapid growth of pyogenic granulomas (PGs). They are benign vascular proliferations, but the specific pathophysiology of these lesions is unknown.

Originally, pyogenic granulomas (PGs) were thought to be caused by bacterial infection; the etiology has yet to be determined. Postulated etiologies include viral, hormonal, and, more recently, angiogenic factors.

Pyogenic granulomas have been evaluated for the presence of human papillomavirus (HPV) because warts occur in similar age groups and sites. Lesions were tested for HPV 6, 11, 16, 31, 33, 35, 42, and 58. No viruses were present.

Recurrent pyogenic granuloma with satellitosis is an uncommon variant. In one patient with recurrent pyogenic granuloma with satellitosis, Warthin-Starry staining of the lesions revealed clumps of dark bacilli as found in patients with bacillary angiomatosis. [5] An indirect immunofluorescence assay showed elevated immunoglobulin G antibodies against Bartonella (Rochalimaea) henselae. The patient did not present an obvious risk for human immunodeficiency virus (HIV) infection or immunosuppression; no antibodies against HIV-1 and HIV-2 were found. Recurrent pyogenic granulomas with satellitosis may be a localized variant of bacillary angiomatosis.

Pyogenic granulomas (PGs) account for 0.5% of skin lesions in infants and children and are also found in the oral mucosa in 2% of pregnant women.

No substantial difference in incidence is found between races.

One study of 178 patients younger than 17 years reported the male-to-female ratio as 3:2. [16] In adults, pyogenic granulomas are more common in females because of pregnancy-related lesions.

Pyogenic granulomas are most common in the first 5 years of life. [17]

Prognosis is excellent after simple removal and wound care. Most pyogenic granulomas (PGs) are asymptomatic except for mild tenderness and a tendency to bleed with little or no trauma. They are benign and easily treated. Rarely, pyogenic granulomas in unusual sites such as the intestines may result in significant bleeding [18, 19, 20] or other major complications. [21]

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Brian Keene, DO Staff Physician, Department of Family Medicine, Tripler Army Medical Center

Brian Keene, DO is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Clark H Cobb, III, MD Assistant Professor of Family Medicine, Uniformed Services University of Health Sciences; Assistant Clinical Professor of Family Medicine, Philadelphia College of Osteopathic Medicine, Georgia Campus; Affiliate Faculty, Family Medicine Residency Program, Columbus Regional Medical Center; Lecturer, Hughston Sports Medicine Clinic

Clark H Cobb, III, MD is a member of the following medical societies: American Academy of Family Physicians, Uniformed Services Academy of Family Physicians

Disclosure: Nothing to disclose.

Yevgeniy Zenchenko, MD Resident Physician, Department of Family Medicine, Tripler Army Medical Center

Yevgeniy Zenchenko, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Robert A Schwartz, MD, MPH Professor and Head of Dermatology, Professor of Pathology, Pediatrics, Medicine, and Preventive Medicine and Community Health, Rutgers New Jersey Medical School; Visiting Professor, Rutgers University School of Public Affairs and Administration

Robert A Schwartz, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, New York Academy of Medicine, American Academy of Dermatology, American College of Physicians, Sigma Xi

Disclosure: Nothing to disclose.

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Kevin P Connelly, DO Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University School of Medicine; Medical Director, Paws for Health Pet Visitation Program of the Richmond SPCA; Pediatric Emergency Physician, Emergency Consultants Inc, Chippenham Medical Center

Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, American Osteopathic Association

Disclosure: Nothing to disclose.

Brett Steinberg, DO Primary Care/Internal Medicine, Staff Physician, US Army Medical Activity, Bavaria

Brett Steinberg, DO is a member of the following medical societies: American Osteopathic Association

Disclosure: Nothing to disclose.

Mark A Crowe, MD Assistant Clinical Instructor, Department of Medicine, Division of Dermatology, University of Washington School of Medicine

Mark A Crowe, MD is a member of the following medical societies: American Academy of Dermatology and North American Clinical Dermatologic Society

Disclosure: Nothing to disclose.

Pediatric Pyogenic Granuloma

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