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    Drugs & Diseases>Dermatology

    Pyogenic Granuloma (Lobular Capillary Hemangioma)

    Updated: Jan 06, 2025
    • Author: Joseph C Pierson, MD; Chief Editor: William D James, MD  more...
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    Overview

    Background

    Pyogenic granuloma (lobular capillary hemangioma) is a relatively common benign vascular lesion of the skin and mucosa whose exact cause remains to be determined. [1, 2] (See also Oral Pyogenic Granuloma.) The term pyogenic granuloma is actually a misnomer, in that these lesions are neither infectious nor granulomatous.

    The lesion usually occurs in children and young adults as a solitary glistening red papule or nodule that is prone to bleeding and ulceration. Pyogenic granulomas typically evolve rapidly over a period of a few weeks, most often on the head, neck, extremities, and upper trunk.

    Pyogenic granuloma often arises in pregnancy (or, rarely, with oral contraceptive usage), particularly on the gingiva or elsewhere in the oral mucosa, [3] and then is termed the pregnancy tumor.

    Other pyogenic granuloma variants that have been well documented include the following subtypes:

    • Disseminated
    • Subcutaneous
    • Intravenous (IV)
    • Medication-induced (eg, by retinoid, antiretroviral, or oncologic agents)

    Removal of pyogenic granuloma is indicated to alleviate any bleeding, discomfort, cosmetic distress, and diagnostic uncertainty. A number of malignant tumors may clinically mimic pyogenic granuloma, making histopathologic confirmation important if the presentation is atypical.

    Aside from cutaneous and oral lesions, pyogenic granuloma has been reported throughout the gastrointestinal (GI) tract and the upper airway and at various ocular locations, as well as in the central nervous system (CNS), the bladder, and the internal vasculature. This article discusses only cutaneous and oral involvement.

    Next: Pathophysiology

    Pathophysiology

    The precise mechanism through which pyogenic granuloma develops has not been elucidated. Trauma, hormonal influences, certain medications, viruses, underlying microscopic arteriovenous malformations (AVMs), production of angiogenic growth factors, and cytogenetic abnormalities have all been postulated to play a role. Overexpression of transcription factors P-ATF2 and STAT3 also may play a role in tumorigenesis. [4]

    Endothelial nitric oxide synthases (eNOS), CD34, and CD105/endoglin expression are markers of angiogenesis in pyogenic granulomas. [5, 6]  Tissue injury may trigger pathologic angiogenesis driven by FLT4, a tyrosine kinase receptor, and the nitric acid pathway. [7] COX-2 and interleukin (IL)-10 may be involved in the etiopathogenesis of oral pyogenic granulomas. [8]  BRAF and RAS mutations have been identified, suggesting a true neoplastic process. [9, 10]  Autophagy may play a part in the pathogenesis of pyogenic granuloma. [11]

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    Etiology

    The cause of the typical pyogenic granuloma is not known. Trauma, hormonal influences, viruses, [12, 13] underlying microscopic AVMs, production of angiogenic factors, foreign bodies, [14]  and cytogenetic clonal deletion abnormalities [15] have all been implicated. Although trauma was long considered a primary cause of pyogenic granuloma, one large study found that only 7% of patients had a history of preceding trauma. [16]

    Development of the lesions with the use of certain medications (retinoids, antiretrovirals, oncologic agents, and others) has been well documented (see History). A report by Al-Zahawi et al described a case of eruptive pyogenic granuloma occurring after COVID-19 vaccination. [17]  Another report by Maronese et al illustrated a case of eruptive pyogenic granuloma that presented 1 month after recovery from mild COVID-19. [18]

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    Next: Pathophysiology

    Epidemiology

    United States and international statistics

    Pyogenic granuloma is relatively common, representing 0.5% of all skin nodules in children. [16] The "pregnancy tumor" variant of pyogenic granuloma occurs in as many as 5% of pregnancies. [19]  The international frequency of pyogenic granuloma is likely similar to that in the United States.

    Age-, sex-, and race-related demographics

    Pyogenic granuloma is rare in children younger than 6 months. The peak age of onset for cutaneous lesions is the second decade of life. [20] For patients younger than 17 years, the mean age of presentation has been reported as 6.7 years. [16] With the exception of lesions occurring in pregnancy, the frequency declines linearly with age in adulthood. (See also Pediatric Pyogenic Granuloma.)

    Pyogenic granulomas are equally prevalent in male and female patients, though oral mucosal lesions are twice as common in females, [2] probably as a consequence of the pregnancy tumor phenomenon. [3, 20]

    No racial predilection has been identified.

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    Prognosis

    Although pyogenic granuloma is a benign lesion, discomfort and bleeding occasionally may be significant. In rare instances, bleeding may be severe enough to cause anemia.

    Lesions that recur despite repeated excisions can be particularly problematic. Pyogenic granulomas can recur regardless of the therapeutic modality employed. In one case of a recurrent, intractable pyogenic granuloma, the culprit was a missed foreign body. [21] Of the surgical treatment options, full-thickness skin excision appears to yield the lowest chance of recurrence (2.94%). [22]  

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    Patient Education

    If a traumatic provoking factor is clearly causing the pyogenic granuloma, it should be avoided. Patients should be instructed to avoid retinoids if their pyogenic granuloma can be attributed to such agents.

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