Pyogenic granuloma is a common benign vascular proliferative lesion presenting as a rapidly growing, friable red papule or polyp that bleeds easily. Despite the name, it is neither pyogenic nor granulomatous; histologically, it is a lobular capillary hemangioma. Triggers include minor trauma, hormonal changes (pregnancy), and some medications. Diagnosis is clinical supported by dermoscopy; histopathology confirms atypical or recurrent cases. Management includes hemostasis and removal via shave excision with curettage and cautery, laser, or surgical excision; topical agents can be considered for small lesions or in children.
Epidemiology and Triggers
- Occurs at any age; peaks in children/young adults.
- Sites: head/neck, fingers, lips, gingiva; periungual lesions common in nail biters/pickers.
- Pregnancy tumors (granuloma gravidarum) on the gingiva or skin in 1st–2nd trimester; often regress postpartum.
- Drug-associated: retinoids, indinavir, isotretinoin, EGFR inhibitors, ramucirumab, BRAF inhibitors.
Clinical Features
- 2–10 mm bright red to violaceous papule or pedunculated polyp; surface often eroded/crusted; bleeds with minor trauma.
- Periungual lesions can cause onycholysis; satellite lesions may develop after partial treatments.
Differential Diagnosis
- Amelanotic melanoma, BCC/SCC, Kaposi sarcoma, bacillary angiomatosis, Spitz nevus, glomus tumor (subungual pain), hemangioma, warts (periungual).
- Oral lesions: peripheral giant cell granuloma, peripheral ossifying fibroma.
Diagnosis
- Dermoscopy: homogeneous red area, white “collarette,” intersecting white lines, polymorphous vessels; ulceration/crust common.
- Biopsy/excision for diagnosis if atypical site, unusual appearance, recurrence, large size, or concern for amelanotic melanoma/KS.
Management
- First-line procedural
- Shave excision with curettage of base and hemostasis by electrocautery or chemical cautery (silver nitrate, aluminum chloride).
- Surgical excision with narrow margins for recurrent, large, or subungual lesions; lower recurrence but larger scar.
- Laser options: pulsed dye laser, 532 nm KTP, CO2; useful for facial/cosmetic sites.
- Topical/medical options (small lesions, pediatric, or when procedures undesirable)
- Topical timolol 0.5% gel bid; multiple weeks; good for small facial lesions.
- Topical imiquimod 5% or ingenol mebutate have case-level support; variable irritation.
- Sclerotherapy with polidocanol for select lesions.
- Special situations
- Pregnancy: conservative approach if possible; many regress postpartum; if treatment needed, use minimally invasive options with attention to bleeding.
- Periungual: consider surgical excision with matrix cautery to reduce recurrence; protect from trauma and address behaviors (biting/picking).
- Recurrence and Aftercare
- Recurrence rates 5–15% after shave/cautery; lower with full-thickness excision.
- Post-procedure wound care and avoidance of trauma; review medications that may contribute.
References (recent guidelines and key reviews)
- Clinical and dermoscopic features of pyogenic granuloma, 2021–2024.
- Comparative outcomes of surgical vs laser vs topical therapies, 2021–2024.
- Drug-induced and pregnancy-associated PG literature, 2022–2024.