JOURNAL READING

Pediatric Piogenik Granuloma

Diajukan guna melengkapi tugas Kepaniteraan Klinik

Bagian Ilmu Kesehatan Kulit dan Kelamin
Rumah Sakit Umum Daerah dr. H. Soewondo Kendal

Disusun Oleh:

Willy Agung R. (012096046)

Yulia Utami Anggarani (012096051)
Yuna Noor Rosida (012096052)

Pembimbing:
dr. Nurul Kawakib, Sp.KK

FAKULTAS KEDOKTERAN
UNIVERSITAS ISLAM SULTAN AGUNG
SEMARANG
2014

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 HALAMAN PENGESAHAN

Disusun Oleh :
Willy Agung R. (012096046)
Yulia Utami Anggarani (012096051)
Yuna Noor Rosida (012096052)

Fakultas : Kedokteran
Universitas : Universitas Islam Sultan Agung Semarang ( UNISSULA )
Tingkat : Program Pendidikan Profesi Dokter
Bagian : Ilmu Kesehatan Kulit dan Kelamin
Judul : Pediatric Piogenik Granuloma

Kendal, November 2014

Mengetahui dan Menyetujui
Pembimbing Kepaniteraan Klinik
Bagian Ilmu Kesehatan Kulit dan Kelamin RSUD dr. H. Soewondo

Pembimbing

dr. Nurul Kawakib, Sp.KK

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 Granuloma Piogenik Pediatrik
author heading Author: Brett Steinberg, DO; Chief Editor: Dirk M
Elston, MD

Latar belakang

Granuloma piogenik (PG) adalah lesi vaskular jinak yang terjadi

paling sering pada kulit akral anak. [1, 2] Istilah granuloma piogenik adalah
sebuah masalah. Awalnya, lesi tersebut diduga disebabkan oleh infeksi
bakteri; Namun, etiologi belum bisa dipastikan. Gambaran histopatologis
cukup khas; lesi ini, pada kenyataannya, merupakan hemangioma kapiler
lobular. [3]
Pengakuan granuloma piogenik sebagai lesi dibatasi klinis
polypoid atau exophytic yang sangat penting untuk dokter dan ahli
patologi karena fitur ini membedakan granuloma piogenik dari
kebanyakan tumor ganas pembuluh darah. Meskipun granuloma piogenik
mungkin jarang (terutama pada kulit) dan umumnya terdapat
nekrosis,adanya invasi struktur yang berdekatan tidak teramati. Lesi
tumbuh dengan cepat dan sangat pada jaringan bervaskular, sering terjadi
perdarahan baik secara spontan atau setelah trauma kecil.[4] Mereka
biasanya mudah diobati dengan operasi pengangkatan tapi juga bisa
terjadi kekambuhan.
[5, 6, 7]
Klasifikasi: granuloma piogenik dengan satellitosis,
[8]
granuloma piogenik intravena, granuloma piogenik subkutan, [9, 10] dan
[11, 12, 13]
granuloma piogenik erupsi. lesi satelit granuloma piogenik yang
lebih kecil mungkin berkembang pada saat yang sama dengan lesi primer
atau dapat terjadi setelah mencoba pengobatan lesi primer. Lihat gambar
di bawah.

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Gambar 1

Granuloma piogenik biasanya lesinya soliter. Jari-jari dan tangan adalah

lokasi umum untuk berkembangnya lesi ini. Perkembangan lesi ini
tersering dilokasi lama setelah riwayat trauma kecil.
Gambar 2

Granuloma piogenik biasanya mengalami perdarahan setelah riwayat

trauma atau tanpa trauma. Pasien ini menunjukkan tanda perban positif.
Karena lesi begitu mudah mengalami perdarahan, pasien sering datang
dengan perban menutupi situs (lokasi lesi).

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Gambar 3

Granuloma piogenik biasanya memiliki tepi yang berbeda yang terdiri

dari tepi keratin (kulit kering). Perhatikan area lembab kulit yang
dihasilkan oleh perban yang telah dibersihkan tak lama sebelum foto
diambil.

Gambar 4

Granuloma piogenik dapat bertangkai dan ukurannya dapat cukup besar.

Suatu daerah nekrosis juga umum ditemukan.

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Gambar 5

Granuloma piogenik dapat terjadi di berbagai tempat. Lebih dari 60%

dari semua lesi berkembang pada kepala dan leher

Gambar 6

Gambar: Small pyogenic granuloma.

Patofisiologi

Meskipun sebagian besar pasien (74,2%) tidak memiliki riwayat

trauma atau predisposisi kondisi dermatologi, kasus terbaru yang
terbanyak, dikarenakan riwayat trauma di lokasi lesi. Sejumlah besar lesi
dapat terjadi kerusakan didaerah kulit dengan luka bakar atau trauma
[14, 15]
lainnya. Sebuah reaksi oksida mekanisme sintesis nitrat diduga
berkontribusi terhadap angiogenesis dan percepatan pertumbuhan dari

6
granuloma piogenik. Mereka adalah proliferasi vaskular jinak, namun
patofisiologi spesifik dari lesi ini belum diketahui.

Epidemiologi

Frekuensi
di Amerika Serikat lesi kulit Granuloma Piogenik mencapai 0,5%
pada bayi dan anak-anak dan juga ditemukan pada mukosa mulut 2%
pada wanita hamil.
Mortalitas / Morbiditas
Kebanyakan granuloma piogenik asimtomatik kecuali untuk kulit
sensitif dan kecenderungan untuk terjadinya perdarahan dengan sedikit
atau tanpa trauma. Lesi ini jinak dan mudah diobati. Jarang, granuloma
piogenik di temukan dilokasi yang tidak biasa, seperti usus yang dapat
[16, 17, 18]
menyebabkan perdarahan yang signifikan atau terjadi komplikasi
lainnya. [19]
Ras
Tidak ada perbedaan substansial yang ditemukan dalam insiden
terjadinya lesi ini.
Seks
Satu studi dari 178 pasien yang ditemukan pada usia lebih muda
yaitu kurang dari 17 tahun melaporkan rasio laki:perempuan adalah
3:2.[20] Pada orang dewasa, granuloma piogenik lebih sering terjadi pada
wanita karena lesi ini berhubungan dengan kehamilan.
Usia
Granuloma piogenik yang paling umum sering ditemukan pada
usia 5 tahun pertama kehidupan. [21]

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Sejarah

Pasien dengan granuloma piogenik (PG) biasanya datang dan

mencari perawatan karena lesi yang telah berkembang dengan pesat dan
mudah berdarah. Pasien atau orang tua mungkin khawatir karena lesi
berdarah dengan sedikit atau tanpa trauma; mereka sering khawatir
bahwa pertumbuhan yang cepat dan perdarahan mungkin menunjukkan
keganasan.
Beberapa pertanyaan penting sebagai berikut:
Apakah riwayat trauma di lokasi lesi sebelum perkembangan lesi
merupakan penyebab?
Granuloma piogenik dapat terjadi setelah trauma fisik ringan atau luka
bakar.
Berapa lama lesi muncul?
Kebanyakan granuloma piogenik berkembang dengan cepat. Durasi rata-
rata pada saat diagnosis adalah sekitar 3 bulan. Jika lesi telah muncul
lebih dari 6 bulan, kemungkinan keganasan pada kulit.
Apakah lesi mudah berdarah?
Hampir semua granuloma piogenik mudah berdarah. Jika lesi tidak
berdarah dengan menggosok ringan, diagnosis granuloma piogenik
diragukan.
Terapi terbaru apa yang telah digunakan?
Nevi, kutil, atau lesi lain mungkin telah diperlakukan dengan agen
kaustik atau cryotherapy sebelum rujukan. Terapi tersebut dapat secara
nyata mengubah tampilan lesi awal, terapi ini dapat ditiru untuk
menangani granuloma piogenik.
Bagaimana jika terjadi pada pasien hamil?
Granuloma piogenik oral dapat berkembang selama atau setelah trimester
pertama kehamilan. Memeriksa dan mengidentifikasi lesi ini pada

8
kehamilan untuk menghindari misdiagnosis dan overtreatment. Lesi ini
umumnya tidak berbahaya pada kehamilan; Namun, induksi persalinan
telah dilaporkan dapat menyebabkan terjadinya pendarahan dari lesi pada
gingiva. [22, 23, 24, 25, 26, 27]
Apakah lesi dapat kambuh setelah pengobatan bedah?
Jika demikian, apakah itu dipotong dan kulit ditutup atau lesi itu diobati
dengan penghapusan bercukur dan electrodesiccation dari dasar?
Granuloma piogenik bisa kambuh. Hal ini lebih mungkin ketika lesi tidak
lengkap diangkat, tetapi kekambuhan juga mungkin terjadi setelah
penghapusan atau pengangkatan yang tampaknya sudah lengkap.
Granuloma piogenik lebih mungkin untuk kambuh setelah penghapusan
bercukur dan electrodesiccation dari dasar daripada setelah eksisi bedah.
Apakah pasien menggunakan terapi retinoid oral (isotretinoin
[Accutane]) baru-baru ini?
Facial piogenik lesi granuloma selama terapi isotretinoin telah
dilaporkan.

Fisik

Granuloma piogenik muncul nodul halus, warna merah atau

kehitaman. Soliter, mempunyai tepi, berbentuk kubah, ukuran 1-10 mm
dan bertangkai. Pada anak-anak lokasi paling sering kepala leher
(62,4 %), Badan (19,7 %), ekstermitas atas (12,9%), tungkai bawah
(5%). Pada kulit (88,2%) dan sisanya selaput lendir rongga mulut
dan konjungtiva.
Pada wanita hamil, granuloma piogenik yang paling sering
ditemukan pada mukosa gingiva [24, 28] tetapi mereka telah dikenal untuk
muncul di daerah nonoral seperti jari dan lipatan inguinal.

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Granuloma piogenik dapat terjadi dalam port-wine stain; kehadiran tanda
lahir vaskuler di wilayah granuloma piogenik mungkin signifikan.
Melanoma amelanotic mungkin sangat menyerupai granuloma piogenik
dalam penampilannya. Meneliti kulit yang berbatasan langsung dengan
lesi untuk setiap penyimpangan pigmentasi.

Etiologi

Awalnya, granuloma piogenik diduga disebabkan oleh infeksi

bakteri; etiologi belum dapat dipastikan. Etiologi termasuk virus,
hormonal, dan yang terbaru adalah faktor angiogenik.
Granuloma piogenik telah dievaluasi untuk kehadiran human
papillomavirus (HPV) karena kutil terjadi pada kelompok usia dan situs
yang sama. Lesi diuji untuk HPV 6,11,16,31,33,35,42 dan 58.Tidak ada
virus yang muncul.
Granuloma piogenik berulang dengan satellitosis merupakan varian
biasa. Pada satu pasien dengan granuloma piogenik berulang dengan
satellitosis, pewarnaan Warthin-Starry dari lesi mengungkapkan
gumpalan basil gelap seperti yang ditemukan pada pasien dengan
angiomatosis basiler.[5] Sebuah uji imunofluoresensi tidak langsung
menunjukkan peningkatan imunoglobulin G antibodi terhadap Bartonella
(Rochalimaea) henselae. Pasien tidak mempunyai risiko untuk human
immunodeficiency virus (HIV) atau imunosupresi; tidak ada antibodi
terhadap HIV-1 dan HIV-2 yang dapat ditemukan. Granuloma piogenik
berulang dengan satellitosis mungkin varian lokal dari angiomatosis
basiler.

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Prosedur

Mendapatkan biopsi dari setiap lesi yang dicurigai sebagai

granuloma piogenik (PG) untuk membantu mengkonfirmasikan
diagnosis.

Histologis

Muncul proliferasi dari kapiler, dengan sel-sel endotel superficial

tertanam dalam edematous stroma agar-agar dalam konfigurasi
karakteristik lobular (lihat gambar di bawah).

Gambar histologis menunjukkan erosi epidermis dan pengerasan kulit,

epidermis menipis, proliferasi pembuluh darah, dan peradangan
bercampur dengan limfosit, histiosit, dan neutrofil. Courtesy of Medscape
Dermatology.

Epidermis umumnya terkikis.

Sebuah infiltrasi padat dan jaringan granulasi dengan leukosit
polimorfonuklear kemungkin ada.
Hiperproliferasi epidermis biasanya muncul pertumbuhan di tepi
pembuluh darah, yang menghasilkan collarette dari epidermis. [29, 20, 30]

11
Surgery

Pengobatan granuloma piogenik (PG) paling sering terdiri dari

penghapusan bercukur dan elektrokauter atau eksisi bedah dengan
penutupan primer.[31] Penghapusan lesi diindikasikan untuk perdarahan
akibat trauma, rasa tidak nyaman, kosmetik, dan untuk biopsi diagnostik.
Lesi dapat benar-benar diangkat selama biopsi.
Untuk lesi soliter, eksisi bercukur dan elektrokauter dengan
anestesi lokal adalah pengobatan pilihan. Untuk memberikan angka
kesembuhan yang memadai, semua pembuluh darah jaringan granulasi
harus dihilangkan atau dibakar.
Untuk lesi besar atau berulang, eksisi bedah dengan penutupan
primer mungkin lebih efektif. Satu studi melaporkan tingkat kekambuhan
43,5% di 23 lesi diobati dengan mencukur (intradermal) eksisi dan kauter
atau kauter saja. Lesi diobati dengan eksisi kulit full-thickness dan
penutupan linear supaya tidak terulang kembali.
Terapi dengan laser vaskular berdenyut-dye khusus pada 585 kasus
sangat selektif, biasanya tidak memerlukan anestesi, dan menghasilkan
hasil kosmetik yang sangat baik. [32, 33] Laser berdenyut-dye bekerja cukup
baik untuk granuloma piogenik intraoral, seperti yang diamati dalam
perempuan hamil.Walaupun pengobatan tersebut layak, pengobatan
selama kehamilan tidak diperlukan karena lesi bisa kambuh selama
kehamilan dan umumnya sembuh sendiri. Berbagai laser lainnya juga
telah terbukti efektif dalam mengobati granuloma piogenik. [34, 35, 36, 37]
Cryotherapy atau terapi perak nitrat mungkin efektif untuk lesi yang
sangat kecil dan ditunjukkan tingkat kekambuhan yang rendah (1,62%).
Namun, jika manajemen nonsurgical dilakukan. Kauterisasi dengan perak
nitrat harus menjadi pengobatan lini pertama. [38, 39 40]

12
Dalam kasus pediatrik, campuran eutektik dari anestesi lokal (EMLA)
diterapkan pada lesi dan kulit di sekitarnya untuk 1-2 jam sebelum
anestesi intralesi yang mungkin merupakan tambahan nilai yang
signifikan.
Pilihan pengobatan baru dapat mencakup pengobatan topikal
dengan imiquimod 5% krim. Ini adalah imidazoquinoline sintetis
heterosiklik amina yang meningkatkan induksi sitokin, baik bawaan dan
diperoleh jalur kekebalan tubuh, sehingga didapat imunomodulasi,
antivirus, dan efek antitumor. [40, 41, 42] Data Definitive kemanjurannya dan
keselamatan di kelompok usia pediatrik tidak ditetapkan, tetapi ada
laporan kasus yang berbeda tentang penggunaannya dalam pengobatan
moluskum kontagiosum, kutil anogenital, hemangioma dan baru-baru ini
[43]
pada granuloma piogenik hasil pengobatan. yang memuaskan dengan
jaringan parut minimal, dan efek samping yang serupa dengan yang
diamati pada pasien dewasa. [44]

Konsultasi

Pertimbangkan rujukan ke dokter spesialis kulit jika diagnosis

diragukan atau jika ketersediaan terapi yang memadai dipertanyakan.

Obat Ringkasan

Meskipun terkadang ditemukan nekrosis, bau busuk, dan drainase

purulen pada granuloma piogenik (PG), terapi antibiotik jarang
diperlukan.

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Rawat Jalan

Setelah penghapusan atau pengangkatan granuloma piogenik (PG),

perawatan luka rutin adalah satu-satunya pengobatan yang diperlukan.
Kunjungan Tindak lanjut diperlukan jika terjadi lesi berulang. Jika
terjadi lesi berulang dan histopatologi yang didapat menegaskan
diagnosis, lesi dapat diobati dengan salah satu modalitas yang dibahas
sebelumnya, termasuk juga dalam mengulangi terapi awal.

Komplikasi

a) Infeksi sekunder
b) Perulangan lesi di lokasi yang sama
c) Kekambuhan beberapa lesi satelit disekitar daerah lesi awal.
d) Pembentukan bekas luka yang dangkal.
e) Granuloma piogenik oral:
Muncul setelah atau selama trisemester kehamilan
Biasanya, granuloma piogenik oral massanya tumbuh lambat dan
tidak minimbulkan cacat besar setelah eksisi yang membutuhkan
perbaikan bedah.
Jarang, tumor besar yang tumbuh dengan pesat terjadi perdarahan
yang signifikan.

Prognosa

Prognosis sangat baik setelah penghapusan sederhana dan

perawatan luka.

14
 Pediatric Pyogenic Granuloma
author heading Author: Brett Steinberg, DO; Chief Editor: Dirk M Elston, MD

Background
Pyogenic granulomas (PGs) are benign vascular lesions that occur most
commonly on the acral skin of children.[1, 2] The term pyogenic granuloma
is a misnomer. Originally, these lesions were thought to be caused by
bacterial infection; however, the etiology has not been determined. The
histopathologic appearance is fairly characteristic; the lesion is, in fact, a
lobular capillary hemangioma.[3]
Recognition of pyogenic granuloma as a clinically polypoid or exophytic
circumscribed lesion is of importance to the clinician and pathologist
because this feature distinguishes pyogenic granulomas from most
malignant vascular tumors. Although pyogenic granulomas may be
multiple (especially on the skin) and necrosis is common, invasion of
adjacent structures is not observed. The lesions grow rapidly and are
extremely vascular, frequently bleeding either spontaneously or after
minor trauma.[4] They are usually easily treated with surgical removal but
may recur.
Uncommon variants include pyogenic granuloma with satellitosis,[5, 6, 7]
intravenous pyogenic granulomas,[8] subcutaneous pyogenic
granulomas,[9, 10]
and eruptive pyogenic granulomas.[11, 12, 13]
Satellite
lesions of smaller pyogenic granulomas may develop at the same time as
the primary lesion or may occur after attempted treatment of the primary
lesion. See the images below.

15
Pyogenic granulomas are usually solitary lesions. The fingers and hands
are common locations for these to develop. A history of minor trauma at
the site shortly before development of the lesion is frequent.

Pyogenic granulomas usually bleed with little or no trauma. This patient

shows a positive bandage sign. Because the lesions bleed so easily,
patients frequently present with a bandage covering the site.

16
Pyogenic granulomas usually have a distinct margin that consists of a rim
of keratin (dry skin). Notice the moist area of skin produced by the
bandage, which was removed shortly before the photograph was taken.

Pyogenic granulomas may be pedunculated and quite large. An area of

necrosis is also common.

Pyogenic granulomas may occur at various sites. More than 60% of all
lesions develop on the head and neck.

Small pyogenic granuloma.

17
Pathophysiology
Although most patients (74.2%) do not have a history of trauma or
predisposing dermatologic conditions, in many cases, a history of recent
trauma at the site is present. Large numbers of lesions may occur
following damage to diffuse areas skin by burns or other trauma. [14, 15] A
nitric oxide synthasedependent mechanism is thought to contribute to
angiogenesis and the rapid growth of pyogenic granulomas. They are
benign vascular proliferations, but the specific pathophysiology of these
lesions is unknown.

Epidemiology
Frequency
United States
Pyogenic granulomas account for 0.5% of skin lesions in infants and
children and are also found in the oral mucosa in 2% of pregnant women.
Mortality/Morbidity
Most pyogenic granulomas are asymptomatic except for mild tenderness
and a tendency to bleed with little or no trauma. They are benign and
easily treated. Rarely, pyogenic granulomas in unusual sites such as the
intestines may result in significant bleeding[16, 17, 18]
or other major
complications.[19]
Race
No substantial difference in incidence is found between races.
Sex
One study of 178 patients younger than 17 years reported the male-to-
female ratio as 3:2.[20] In adults, pyogenic granulomas are more common
in females because of pregnancy-related lesions.
Age
Pyogenic granulomas are most common in the first 5 years of life.[21]

18
History
Patients with pyogenic granulomas (PGs) usually seek care because the
lesion has grown rapidly and bleeds easily. Patients or parents may be
concerned because the lesion bleeds with little or no trauma; they are
frequently concerned that the rapid growth and bleeding may indicate a
malignancy.
Important questions include the following:
Does the history include trauma at the site prior to development of the
lesion? Pyogenic granulomas may occur following minor physical
trauma or burns.
How long has the lesion been present? Most pyogenic granulomas
develop rapidly. The mean duration at the time of diagnosis is
approximately 3 months. If the lesion has been present longer than
6 months, the possibility of cutaneous malignancy increases.
Does the lesion bleed easily? Almost all pyogenic granulomas bleed
easily. If the lesion does not bleed with light rubbing, a diagnosis
of pyogenic granuloma is unlikely.
What therapy has been used recently? Nevi, warts, or other lesions may
have been treated with caustic agents or cryotherapy prior to
referral. Such therapy may markedly change the appearance of the
original lesion, causing it to mimic a pyogenic granuloma.
Is the patient pregnant? Oral pyogenic granulomas can develop during
or just after the first trimester of pregnancy. Examine and properly
identify these lesions of pregnancy to avoid misdiagnosis and
overtreatment. These lesions are not generally harmful in
pregnancy; however, induction of labor due to uncontrollable
bleeding from a gingival lesion has been reported.[22, 23, 24, 25, 26, 27]
Has the lesion recurred after surgical treatment? If so, was it excised
and the skin closed primarily or was it treated with shave removal

19
 and electrodesiccation of the base? Pyogenic granulomas may
recur. This is more likely when they are incompletely removed, but
recurrence is also possible after apparently complete removal.
Pyogenic granulomas are more likely to recur after shave removal
and electrodesiccation of the base than after surgical excision.
Has the patient taken oral retinoid therapy (isotretinoin [Accutane])
recently? Facial pyogenic granulomalike lesions during
isotretinoin therapy have been reported.

Physical
Pyogenic granulomas appear as smooth firm nodules, with or
without crusts, and they may have a bright or dusky red color. They are
usually solitary, well circumscribed, dome shaped, 1-10 mm in
diameter, and sessile or pedunculated.
In children, pyogenic granulomas are most commonly located on
the head and neck (62.4%) and, in order of decreasing frequency, on the
trunk (19.7%), upper extremity (12.9%), and lower extremity (5%).
Most (88.2%) occur on the skin, and the rest involve mucous
membranes of the oral cavity and conjunctivae.
In pregnant women, pyogenic granulomas are most often found on
the gingival mucosa[24, 28] but they have been known to appear in nonoral
areas such as the fingers and inguinal crease.
Pyogenic granulomas may occur within a port-wine stain; the
presence of a vascular birthmark in the region of the pyogenic
granuloma may be significant.
Amelanotic melanoma may closely mimic a pyogenic granuloma
in appearance. Closely examine the skin immediately adjacent to the
lesion for any pigmentary irregularity.

20
Causes
Originally, pyogenic granulomas were thought to be caused by
bacterial infection; the etiology has yet to be determined. Postulated
etiologies include viral, hormonal, and, more recently, angiogenic factors.
Pyogenic granulomas have been evaluated for the presence of
human papillomavirus (HPV) because warts occur in similar age groups
and sites. Lesions were tested for HPV 6, 11, 16, 31, 33, 35, 42, and 58.
No viruses were present.
Recurrent pyogenic granuloma with satellitosis is an uncommon
variant. In one patient with recurrent pyogenic granuloma with
satellitosis, Warthin-Starry staining of the lesions revealed clumps of
dark bacilli as found in patients with bacillary angiomatosis.[5] An indirect
immunofluorescence assay showed elevated immunoglobulin G
antibodies against Bartonella (Rochalimaea) henselae. The patient did
not present an obvious risk for human immunodeficiency virus (HIV)
infection or immunosuppression; no antibodies against HIV-1 and HIV-2
were found. Recurrent pyogenic granulomas with satellitosis may be a
localized variant of bacillary angiomatosis.

Procedures
Obtain a biopsy of any lesion suspected of being a pyogenic granuloma
(PG) to confirm the diagnosis.

Histologic Findings
Proliferation of capillaries is present, with prominent endothelial cells
embedded in edematous gelatinous stroma in a characteristic lobular
configuration (see image below).
Inline figure

21
Histologic image showing epidermal erosion and crusting, thinned
epidermis, vascular proliferation, and mixed inflammation with
lymphocytes, histiocytes, and neutrophils. Courtesy of Medscape
Dermatology.

The epidermis is commonly eroded.

A dense infiltrate and granulation tissue with polymorphonuclear
leukocytes may be present.
Hyperproliferation of the epidermis is usually present at the margins of
the vascular growth, which results in a collarette of epidermis.[29, 20, 30]

Surgical Care
Treatment of pyogenic granulomas (PGs) most commonly consists of
shave removal and electrocautery or surgical excision with primary
closure.[31] Removal of the lesion is indicated for bleeding due to trauma,
discomfort, cosmetic distress, and diagnostic biopsy. The lesion may be
completely removed during biopsy.
For solitary lesions, a shave excision and electrocautery under local
anesthesia is the treatment of choice. To provide an adequate cure rate, all
vascular granulation tissue must be removed or cauterized.
For large or recurrent lesions, surgical excision with primary closure may
be more effective. One study reported a 43.5% recurrence rate in 23

22
lesions treated by shave (intradermal) excision and cautery or cautery
alone. Lesions treated by full-thickness skin excision and linear closure
did not recur.
Therapy with the pulsed-dye laser at vascular-specific 585 nm is very
selective, usually requires no anesthesia, and produces excellent cosmetic
results.[32, 33] The pulsed-dye laser works quite well for intraoral pyogenic
granulomas, as observed in pregnant women. Although treatment is
feasible, treatment during pregnancy is not necessary because the lesions
may recur during the pregnancy and generally resolve with delivery.
Various other lasers have also been shown to be effective in treating
pyogenic granulomas.[34, 35, 36, 37]
Cryotherapy or silver nitrate therapy may be effective for very small
lesions and exhibited a low overall recurrence rate (1.62%). However, if
nonsurgical management is undertaken, cauterization with silver nitrate
should be the first-line treatment.[38, 39, 40]
In pediatric cases, a eutectic mixture of local anesthetics (EMLA) applied
to the lesion and surrounding skin under an occlusive dressing for 1-2
hours prior to additional intralesional anesthesia may be of significant
value.
New treatment options may include topical treatment with imiquimod 5%
cream. It is a synthetic imidazoquinoline heterocyclic amine that
enhances, through cytokine induction, both the innate and acquired
immune pathways, resulting in immunomodulating, antiviral, and
antitumor effects.[40, 41, 42] Definitive data on its efficacy and safety on
pediatric age groups are not established, but there are different case
reports about its use in the treatment of molluscumcontagiosum,
anogenital warts, hemangiomas, and, recently, pyogenic granuloma. [43]
Treatment results were satisfactory with minimal scarring, and adverse
effects were similar to those observed in adult patients.[44]

23
Consultations
Consider referral to a dermatologist if the diagnosis is in doubt or if
the availability of adequate therapy is questionable.

Medication Summary
Despite the necrosis, foul odor, and purulent drainage noted
occasionally with pyogenic granulomas (PGs), antibiotic therapy is rarely
required.

Further Outpatient Care

Following removal of the pyogenic granuloma (PG), routine wound
care is the only treatment required.
Follow-up visits are required only if the lesion recurs. If the lesion
recurs and histopathology confirms the diagnosis, the recurrent
lesion may be treated with any of the modalities previously
discussed, including simply repeating the initial therapy.

Complications
Significant secondary infection (extremely uncommon)
Recurrence at the original site
Recurrence as multiple satellite lesions in the area
immediately surrounding the original lesion
Superficial scar formation
Oral pyogenic granulomas
An oral pyogenic granulomas can develop during or just after the
first trimester of pregnancy.
Usually, an oral pyogenic granulomas is an early slow-growing mass
that, upon excision, does not leave a large defect in the periodontium
that requires surgical repair.

24
 Rarely, a rapidly growing large tumor may produce significant
hemorrhage.

Prognosis
Prognosis is excellent after simple removal and wound care.

25
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