x
x

PYOGENIC GRANULOMA

Introduction

Pyogenic granuloma also known as lobular capillary hemangioma and granuloma teleangiectaticum, is a relatively common benign vascular tumor. It usually appears as a red, rapidly growing lesion of the skin or mucosa, but can also occur intravenously, subcutaneously, and in the gastrointestinal tract. Most pyogenic granulomas occur on the head and neck, but up to 37% of cases involve the forearm, wrist, and hands, with the nails and periungual region being a frequent site of occurrence. These tumors can develop at any age, but are most commonly seen in children, adolescents, and young adults, and pregnant women (where they are referred to as ‘granuloma gravidarum’). Due to their typically rapid initial growth pattern, pyogenic granuloma can be alarming and lead to suspicion of a cutaneous malignant tumor, and therefore must be properly evaluated.1-3

Pathophysiology

  • The exact pathogenic mechanism responsible for pyogenic granuloma is not fully understood, but there are several theories and proposed risk factors that have been associated with its development.1,3,4
  • Acute and chronic trauma, infection, immunosuppression, and sex hormones associated with pregnancy have all been linked to pyogenic granuloma. There are also reports suggesting a connection between pyogenic granuloma and several drugs, including retinoids, antiretroviral drugs, and oral contraceptives, as well as targeted oncological therapies, epidermal growth-factor receptor inhibitors, mitogen-activated protein kinase inhibitors, and rituximab.1,3,4
  • In patients on systemic retinoids such as isotretinoin (Accutane), pyogenic granulomas primarily affect the periungual region and can be numerous/span many digits.

Related Anatomy

  • Dermis
  • Epidermis
  • Skin membranes
  • Mucous membranes
  • Endothelial cells
  • Connective tissue
  • Capillaries
  • Venules
  • Edematous stroma

Incidence and Related Conditions

  • Most pyogenic granulomas develop on the head and neck, but 12-37% involve the hand, wrist, and forearm.2
  • Pyogenic granulomas can occur at any age, but are rare in children younger than 6 months and have a peak incidence in the second and third decades of life. For patients <17 years, the mean age of presentation is 6.7 years.5
  • Granuloma gravidarum
    • Describes the occurrence of PG during pregnancy.
    • Hemangioma

Differential Diagnosis

  • Angioendothelioma
  • Angiolymphoid hyperplasia with eosinophilia
  • Angiosarcoma
  • Bacillary angiomatosis
  • Cutaneous endometriosis
  • Eccrine poroma
  • Foreign body
  • Granulation tissue
  • Hemangioma
  • Hemangioendothelioma
  • Malignant melanoma
  • Masson tumor
  • Neurofibroma
  • Pyoderma gangrenosum
  • Spitz nevus 
ICD-10 Codes

  • SKIN - BENIGN LESIONS: PYOGENIC GRANULOMA

    Diagnostic Guide Name

    SKIN - BENIGN LESIONS: PYOGENIC GRANULOMA

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    PYOGENIC GRANULOMAL98.0   

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Pyogenic granuloma
  • Pyogenic granuloma on the radial aspect of the right index finger in a 23 y.o. right handed college student.
    Pyogenic granuloma on the radial aspect of the right index finger in a 23 y.o. right handed college student.
  • Pyogenic granuloma at the base of the right fifth finger in a 39 y.o. female
    Pyogenic granuloma at the base of the right fifth finger in a 39 y.o. female
Symptoms
Patients complain of erythematous papule or nodule ranging in size from 2-3 mm to 2 cm in diameter
Patients note a nodule that develops spontaneously or follow an untreated laceration.
Most lesions grow rapidly at first and develop into pediculated tumors with an erosive surface.
Patients often complain bleeding from the lesion.
Typical History

A typical patient is a 22-year-old woman who is 31 weeks pregnant. Her pregnancy was otherwise healthy and uneventful, but during week 28, she noticed some red discoloration on her right index finger. Within 1 week, the discoloration had rapidly grown into a smooth, dark red nodule measuring ~1 cm in diameter, and soon thereafter it began to bleed. Fearing that it could be a malignant tumor, she consulted with a dermatologist for an evaluation. 

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • Identify the diagnosis accurately
  • Successful treat the lesion
Conservative
  • Although pyogenic granulomas are benign and some may resolve spontaneously, treatment is usually needed to address bleeding, discomfort, obstruction of nearby structures, or other symptoms.1,3,4
  • Topical therapy
    • Silver nitrate application
    • Imiquimod cream (5%) under occlusion
    • Timolol (0.5%) gel
    • Tretinoin gel
    • Antibiotics if secondarily infected (Staphylococcal spp. most common)
  • Systemic therapy
    • Corticosteroids (expressly reserved for cases of giant and/or recurrent lesions)
  • Intralesional injection
    • Triamcinolone acetonide
    • Sclerotherapy
Operative
  • There is no clear consensus as to when surgical management should be undertaken and when other treatment methods should be considered.1,3,4
  • Destructive methods
    • First line treatment option
    • Curettage or shave excision, followed by electrodessication of the vascular base and/or topical silver nitrate
  • Cryotherapy
  • Laser therapy
    • CO2 laser
    • Pulsed dye laser
  • Surgical excision
    • Curettage, shave, punch, or scalpel excision may be used
Treatment Photos and Diagrams
Pyogenic granuloma
  • Pyogenic granuloma at the base of the left index finger in a 45 y.o. male plumber after unsuccessful treatment with silver nitrate. Patient treated successfully with surgical excision.
    Pyogenic granuloma at the base of the left index finger in a 45 y.o. male plumber after unsuccessful treatment with silver nitrate. Patient treated successfully with surgical excision.
CPT Codes for Treatment Options

Per an agreement between Hand Surgery Resource, LLC and the American Medical Association (AMA) users are required to accept the following End User Point and Click Agreement in order to view CPT content on this website.  Please read and then click "Accept" at the bottom to indicate your acceptance of the agreement.

End User Point and Click Agreement

CPT codes, descriptions and other data only are copyright 2019 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. The AMA reserves all rights to approve any license with any Federal agency.

You, as an individual, are authorized to use CPT only as contained in Hand Surgery Resource solely for your own personal information and only within the United States for non-commercial, educational use for the purpose of education relating to the fundamental principles of hand surgery and the common diseases, disorders and injuries affecting the human hand. You agree to take all necessary steps to ensure your compliance with the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized herein must be obtained through the AMA, CPT Intellectual Property Services, 330 N. Wabash Avenue, Chicago, IL 60611. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt.

Common Procedure Name
Excision pyogenic granuloma (rheumatoid nodule, hemangioma)
CPT Description
Excision of benign tumor subcutaneous
CPT Code Number
26115
CPT Code References

The American Medical Association (AMA) and Hand Surgery Resource, LLC have entered into a royalty free agreement which allows Hand Surgery Resource to provide our users with 75 commonly used hand surgery related CPT Codes for educational promises. For procedures associated with this Diagnostic Guide the CPT Codes are provided above. Reference materials for these codes is provided below. If the CPT Codes for the for the procedures associated with this Diagnostic Guide are not listed, then Hand Surgery Resource recommends using the references below to identify the proper CPT Codes.

CPT QuickRef App.  For Apple devices: App Store. For Android devices: Google Play

CPT 2021 Professional Edition: Spiralbound

Complications
  • Infection
  • Scarring
  • Recurrence
Outcomes
  • Recurrence is common with PGs, with rates ranging from 3.7% to as high as 43.5%.4
  • One study found cryotherapy and surgical excision to be associated with the lowest crude overall recurrence rates, and identified no statistical differences between the two interventions.4
  • Imiquimod 5% appears to be a safe option for adult and pediatric patients, with one study finding that 9 of 10 patients achieved almost complete response to treatment over 2-17 weeks.1
Key Educational Points
  • Patients complain of erythematous papule or nodule ranging in size from 2-3 mm to 2 cm in diameter 1,2
    • Usually smooth 
    • Red to purple in color
    • Sessile or pedunculated
    • Surrounded at its base by a collarette of scale
  • Pyogenic granulomas may develop spontaneously or follow an untreated laceration.
  • Most pyogenic granulomas can grow rapidly at first and develop into pediculated tumors with an erosive surface.2
  • Pyogenic granulomas are often associated with bleeding, erosion and ulceration of the surface
  • Pyogenic granulomas can be purulent with crushing
  • Pyogenic granulomas are defined histologically by a collarette enclosing lobules of endothelial cells and luminal structures in an edematous stroma, and the biopsy will demonstrates both granulation tissue and inflammatory cells.2
  • Sonographic studies (ultrasound) may be helpful when evaluating these lesions
  • Dermatoscopy although helpful, it may be difficult to distinguish pyogenic granulomas from malignant melanoma with this diagnostic tool.
  • Deciding on appropriate treatment should be based on the severity of the condition, localization, and size of the PGs, as well as pertinent patient characteristics and expectations.1
References

New and Cited Articles

  1. Plachouri KM, Georgiou S. Therapeutic approaches to pyogenic granuloma: an updated review. Int J Dermatol 2019;58(6):642-648. PMID: 30345507
  2. Quitkin, HM, Rosenwasser, MP and Strauch, RJ. The efficacy of silver nitrate cauterization for pyogenic granuloma of the hand. J Hand Surg Am 2003;28(3):435-8. PMID: 12772100
  3. Piraccini BM, Bellavista S, Misciali C, Tosti A, de Berker D, Richert B. Periungual and subungual pyogenic granuloma. Br J Dermatol 2010;163(5):941-953. PMID: 20545691
  4. Lee J, Sinno H, Tahiri Y, Gilardino MS. Treatment options for cutaneous pyogenic granulomas: a review. J Plast Reconstr Aesthet Surg 2011;64(9):1216-1220. PMID: 21316320
  5. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol 1991;8(4):267-276. PMID: 1792196
  6. James WD, Berger TG, Elston DM. Andrews’ Diseases of the Skin. 12th Ed. Philadelphia, PA. Elsevier, 2016.

Reviews

  1. Plachouri KM, Georgiou S. Therapeutic approaches to pyogenic granuloma: an updated review. Int J Dermatol 2019;58(6):642-648. PMID: 30345507
  2. Lee J, Sinno H, Tahiri Y, Gilardino MS. Treatment options for cutaneous pyogenic granulomas: a review. J Plast Reconstr Aesthet Surg 2011;64(9):1216-1220. PMID: 21316320
Subscribe to PYOGENIC GRANULOMA
⇡