tumors

Pyogenic Granuloma

Generality

The pyogenic granuloma is a benign vascular tumor, which originates from the rapid and uncontrolled proliferation of an epithelial cell of a blood vessel with a cutaneous or situated on a mucosa.

The precise causes of pyogenic granuloma are unknown; on the basis of certain observations, however, the doctors believe that, on the appearance of the tumor in question, circumstances or events may affect such as: skin wounds, burns, insect bites, pregnancy, use of the contraceptive pill, l 'taking certain drugs (eg chemotherapeutic drugs, systemic retinoids, etc.), cutaneous rubbing wounds, etc.

The typical pyogenic granuloma has the appearance of a red-colored nodule or papule, no more than a couple of centimeters, which, if subjected to shocks, is the protagonist of bleeding.

The treatment of pyogenic granuloma varies in relation to three factors, which are: the size of the tumor, the site of the tumor and the probable factors favoring its formation.

Short review of what a hemangioma is

A hemangioma is a particular benign tumor, belonging to the category of angiomas, which originates from the abnormal proliferation of a typical endothelial cell of the inner wall of blood vessels.

Consisting of a dense agglomeration of capillaries and slightly larger blood vessels, a hemangioma can:

  • Appear as a smooth patch, a raised papule or a nodule of a certain thickness;
  • Be red or purple;
  • Reside on the skin (cutaneous localization), in the dermis, on the mucous membranes or on the internal organs (brain, heart, spleen, liver, respiratory tract, bones etc.).

The word hemangioma derives from the union of three terms of Greek origin: ema, which means blood, angio, which means vase, and oma, which indicates tumor.

Hemangiomas are examples of benign-type vascular tumors.

What is a pyogenic granuloma?

The pyogenic granuloma is a particular type of hemangioma, which can grow on the skin or mucous membranes and which usually presents as a bright red nodule.

The pyogenic granuloma is therefore a vascular tumor of a benign nature.

What is not?

Despite what the terms "granuloma" and "pyogenic" would suggest, the pyogenic granuloma is neither something directly related to an infection nor a purulent formation (ie producing pus).

In other words, the pyogenic granuloma does not respond to the canonical definitions of granuloma and pyogenic, present in pathology texts

In the medical-pathological field, the term "granuloma" indicates an abnormal aggregation of macrophages (cells of the immune system) and, often, also of inflammatory cells, formed as a result of infectious processes, chronic inflammations or adverse reactions to foreign material .

The term "pyogenic", on the other hand, is an adjective that means "producer of pus".

Synonyms of pyogenic granuloma

The pyogenic granuloma has several other names, including:

  • Eruptive hemangioma,
  • Lobular lobular angioma,
  • Telangiectatic Granuloma e
  • Granuloma from pregnancy .

It is one of the three possible subtypes of hemangioma

The pyogenic granuloma is one of the three possible subtypes of hemangioma, which can affect the human being. The other two subtypes are the so-called capillary hemangioma and the so-called cavernous hemangioma .

Table. Subtypes of hemangioma and their main characteristics.
SubtypeLocationAppearance
Capillary hemangioma (ex: ruby ​​angioma and "angioma of the newborn")
  • Skin
  • Smooth patch or papule detected
  • Red or purple color
Cavernous hemangioma or cavernoma (eg liver angioma and vertebral angioma)
  • Derma
  • Internal organs
  • Nodule
  • Red or purple color
Pyogenic granuloma
  • Skin
  • mucous
  • Nodule
  • Red or brown-red color

Causes

The doctors have not yet accurately identified the causes of the pyogenic granuloma, however they have several suspicions; on the basis of some findings, in fact, they believe that various factors can influence the formation of the aforementioned vascular tumor, such as:

  • Traumatic skin wounds and burns . It is not absolutely clear how these events can cause or induce pyogenic granuloma, however the statistics say that between the vascular tumor in question and the various circumstances mentioned above there is a certain consequential link (many individuals develop a pyogenic granuloma after a cutaneous wound or a burn);
  • Insect bites ;
  • The wounds of the skin from continuous rubbing ;
  • The hormonal changes that, in women, characterize the state of pregnancy or the use of the contraceptive pill . According to statistics, the formation of pyogenic granuloma is a phenomenon that affects 5% of pregnant women.

    Currently, it represents a real mystery how the aforementioned hormonal changes can cause the formation of pyogenic granulomas;

  • The bacterium Staphylococcus aureus . This could be in disagreement with what was previously stated ("the pyogenic granuloma is not linked to infectious phenomena"), however it is not a mistake: sometimes, from the examination of a pyogenic granuloma the presence of bacteria belonging to the Staphylococcus aureus species emerges;
  • The use of certain pharmacological products, including systemic retinoids acitretin and isotretinoin, the antiviral drugs belonging to the class of protease inhibitors (eg: indinavir) and chemotherapeutic drugs such as fluorouracil and paclitaxel;
  • Viral infections . A part of the medical-scientific community considers the theory that viruses have a role, even if only marginal, on the formation of pyogenic granulomas absolutely groundless.

Curiosity

The tendency of the pyogenic granuloma to affect pregnant women is the reason why the aforementioned benign vascular tumor is also called pregnancy granuloma.

Pathophysiology

The pyogenic granuloma is the result of the rapid and uncontrolled proliferation of an endothelial cell of a blood vessel, with a cutaneous site or located on a mucosa.

Epidemiology

The pyogenic granuloma is a benign tumor that can affect any ethnic group, so it is widespread throughout the world.

Its formation is rare and uncommon, respectively, in children under 6 months and in adults (including the elderly), while it is quite common in children, young adults and women of child-bearing age (for this last circumstance recalls the relationship between pregnancy and pyogenic granuloma).

Symptoms and complications

At the beginning, the pyogenic granuloma has the appearance of a small patch of red (in most cases) or of an intermediate color between brown and red (minority of cases)

As the days / weeks go by, it becomes progressively larger (generally not exceeding 2 centimeters in diameter, but in rare cases it can even reach 5 centimeters) and takes on the appearance of a papule or nodule ; in the meantime, it could also change its color, going from red to purple, from red to yellow or from red to a middle ground between blue and black.

Sometimes, it leaves behind the appearance of papule / nodule, due to a polypoid conformation, characterized by a sort of collar at the base.

Once matured, the pyogenic granuloma can be the protagonist of bleeding (especially if subjected to trauma or shock), can form a crust and / or can ulcerate, resulting, in the latter case, also very painful .

Where can a pyogenic granuloma form?

The anatomical sites that most frequently host the pyogenic granuloma are: the head, neck, trunk, back and extremities of the limbs (therefore hands, fingers, feet and toes); however, it should be pointed out that, even if rarely, the pyogenic granulomas can grow even on: the labial mucosa, the external genitalia, the eyelids, the intra-oral mucosae, the ocular conjunctiva and the cornea.

For reasons still unknown, in pregnant women, the pyogenic granuloma is classically formed on the intra-oral mucosa of the jaw.

The pyogenic granuloma can be a solitary or multiple presence

The pyogenic granuloma is usually a solitary presence, ie a single nodule or papule; on very rare occasions, however, it can happen that it appears as multiple nodules or papules.

Complications

The pyogenic granuloma is never the object of an evolution in a malicious sense; in other words, it never happens that it becomes a malignant tumor.

The only noteworthy complication, which can lead to the pyogenic granuloma, is the ease of bleeding even after trivial bumps.

Especially large pyogenic granulomas are often bleeding.

Diagnosis

In general, the diagnosis of pyogenic granuloma is based on simple objective examination, ie on the observation of the tumor and its characteristics.

However, in some circumstances, it may happen that the diagnostic doctor intends to investigate what has been observed with a more specific examination, such as the biopsy on a sample of cells from the pyogenic granuloma.

What is biopsy for?

The biopsy is the test that confirms the diagnosis of pyogenic granuloma, established during the previous physical examination.

Fundamental in the presence of doubts, the biopsy also allows to exclude that the detected nodule is a malignant tumor formation ( melanoma or skin cancer different from melanoma ).

Differential diagnosis obtained thanks to biopsy on a pyogenic granuloma:

  • Basal cell carcinoma (skin cancer other than melanoma)
  • Spinocellular carcinoma (skin cancer other than melanoma)
  • Ruby angioma
  • Congenital hemangioma
  • Kaposi's sarcoma
  • Malignant melanoma
  • Metastatic carcinoma of the skin
  • Neo anomalous

Therapy

The treatment of pyogenic granuloma depends mainly on 3 factors, which are:

  • The size of the tumor;
  • The site of the tumor;
  • The probable causes or factors favoring the tumor.

Treatment of a small pyogenic granuloma

Small pyogenic granulomas are formations that could resolve spontaneously; therefore, before implementing a treatment, doctors prefer to wait for the situation to evolve.

In the absence of a spontaneous resolution of the problem, the most indicated treatments against small pyogenic granulomas are:

  • The pulsed laser : removes the pyogenic granuloma by burning it;
  • Cryotherapy : involves the elimination of pyogenic granuloma by freezing.

Treatment of a large pyogenic granuloma

Large granulomas always require therapy, which can be:

  • The curettage followed by cauterization : the curettage consists in the elimination of the pyogenic granuloma by means of a scraping, practiced with a special tool (the curette ); cauterization, on the other hand, is a burning operation, performed where the benign tumor resided, to avoid any recurrences (ie the regrowth of the pyogenic granuloma);
  • Laser therapy (or laser surgery ): works in a similar way to the pulse laser;
  • Silver nitrate : allows the elimination of pyogenic granuloma by burning. It is not always 100% effective;
  • Surgical excision : it is the removal of the pyogenic granuloma made with surgical techniques. Among those proposed, it is the most invasive solution, but also the most effective.

Treatment of pyogenic granuloma with an ocular site

Possible treatments for pyogenic granuloma with an ocular site include: surgical removal of the tumor and the use of ointments for local use, containing corticosteroids (anti-inflammatories).

Treatment of the pyogenic granuloma in pregnant women

The pyogenic granuloma associated with pregnancy is a formation that, in most cases, heals spontaneously after childbirth, when the levels of certain hormones return to normal, so to speak.

Therefore, for pregnant women with a pyogenic granuloma, doctors always advise, first of all, to wait for the conclusion of gestation and see if there is spontaneous healing.

As can be guessed, the lack of spontaneous healing makes it essential to resort to a specific treatment, which may be one of those previously proposed (pulse laser, cryotherapy, surgery, laser therapy, etc.).

Treatment of the pyogenic granuloma due to drugs

In the majority of cases, the pyogenic granulomas due to the assumption of a certain drug regress at the conclusion of the pharmacological administrations; in other words, the treatment of a pyogenic granuloma by pharmacological treatment consists in the interruption of the aforementioned treatment.

Prognosis

Prognosis in the case of pyogenic granuloma is generally benign, even for larger tumors.

A small percentage of patients undergoing treatment is the victim of a relapse (reappearance of the pyogenic granuloma), which however, with a second cycle of therapies, is largely solvable.