Pyogenic Granuloma (Lobular Capillary Hemangioma)

• Solitary, dome-shaped, exophytic (outward-growing) vascular nodule
• Bright red to purplish-red, moist, friable surface
• Well-demarcated base with a white hyperkeratotic epidermal collarette
• Glistening, slightly lobulated texture - highly prone to bleeding with minor trauma

What Is It?

• Trauma or minor skin injury (stimulates excessive vessel proliferation)
• Pregnancy (granuloma gravidarum - especially on gingiva)
• Medications: isotretinoin, capecitabine, vemurafenib, indinavir
• Most common on hands, forearms, face, and oral mucosa

Management

1. First-line: Curettage + Base Destruction

• Shave excision or curettage, followed by fulguration (electrodesiccation) or aluminum chloride to destroy the feeding vessels at the base
• This is the standard approach; allows tissue to be sent for histopathology (important to rule out amelanotic melanoma)

2. Chemical Cauterization

• Silver nitrate sticks - sufficient for small lesions; quick and office-based
• Caution: may leave a silver tattoo; does not provide tissue for pathology

3. Topical Therapies (non-surgical option)

• Topical timolol 0.5% - beta-blocker eye drops applied topically; 77.5% excellent response rate in prospective studies; useful in patients who refuse surgery
• Topical imiquimod under occlusion - immunomodulatory approach
• Topical propranolol - less effective, especially for periungual lesions (~15% resolution)

4. Sclerotherapy

• Monoethanolamine oleate or sodium tetradecyl sulfate injection - effective for recurrent or oral lesions

5. Laser Ablation

• CO2 laser and diode laser - best single-session resolution rates among laser options
• Pulsed dye laser (PDL) - commonly used, especially in children
• Nd:YAG and other lasers show variable success

6. Surgical Excision

• Reserved for recalcitrant or recurrent lesions
• Full-thickness excision eliminates the feeding vessel and reduces recurrence

7. Drug-Induced PG

• Withdraw or reduce the offending drug - lesions regress spontaneously

8. Recurrent / Giant PG

• Systemic corticosteroids have been used for recurrent giant pyogenic granulomas
• Recurring lesions may develop satellite lesions if incompletely removed

Key Points

Note: Always send excised tissue for histopathology to exclude a bleeding amelanotic melanoma, which can clinically mimic a pyogenic granuloma - especially important for lesions on the sole or nail bed.

• Andrews' Diseases of the Skin, p. 683