Pratique clinique Clinical Pract ice
FOR PRESCRIBING INFORMATION SEE PAGE 102
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CAN YOU IDENTIFY THIS CONDITION?
A
66-year-old woman presented with a smooth, soft, red papule on the outer edge of her lower lip.The most likely diagnosis is:
1. Amelanotic melanoma 2. Basal cell carcinoma 3. Squamous cell carcinoma 4. Pyogenic granuloma 5. Kaposi’s sarcoma Answer on page 36
Dr Ting is a recent graduate of the University of Calgary Medical School in Alberta.
Dr Barankin is a dermatology resident at the University of Alberta in Edmonton.
Dermacase
Patricia T. Ting MD, MSC Benjamin Barankin, MD
VOL 52: JANUARY • JANVIER 2006d Canadian Family Physician • Le Médecin de famille canadien 35
Clinical Pract ice Pratique clinique
4. Pyogenic granuloma
Pyogenic granuloma, a common benign lesion of the skin and mucous membranes,1 is characterized by a smooth, dome-shaped, or pedunculated pap- ule or nodule with a glistening surface.2 Th e pap- ules have a soft texture and range from bright red, to dusky red, to violaceous, to brown-black. Th ey can be 5 to 10 mm in diameter1 and might have erosions or crusts. Th ey are misnamed: they are neither pyogenic nor granulomatous.
Conventional pyogenic granulomas most com- monly occur as solitary lesions on the gingiva, lips, mucosae of the nose, trunk, fingers, and toes;1 occasionally, they appear as multiple satellites.3 The highly vascular tumours usually evolve rap- idly and sometimes bleed spontaneously or after minor trauma. Th e classic story of a red papule or nodule that bleeds easily on provocation strongly suggests this lesion. It is common in infants, chil- dren, and young adults.4 Children with a pyogenic granuloma frequently present with a blood-soaked adhesive bandage.5
In addition to conventional pyogenic granulo- mas, there are fi ve rare clinical variants.5
• Satellite pyogenic granuloma is reported after irritation or treatment of the primary lesion and is common in the head or neck region or around the scapula.
• Granuloma gravidarum occurs on the surface of the gingiva in women who are pregnant or taking oral contraceptives.
• Subcutaneous pyogenic granuloma presents as a nonspecifi c subcutaneous nodule on the upper extremities.
• Intravenous pyogenic granuloma presents as a red-brown intravascular polyp in the neck and upper extremities.
• Disseminated pyogenic granuloma presents as multiple pyogenic granulomas on the body.
These lesions have sometimes been there from birth.
Histologically, fully developed pyogenic granu- lomas appear as a lobular proliferation of capil- laries with each lobule containing a central feeder vessel surrounded by smaller capillaries.1 In 1980,
Mills et al6 suggested the term lobular capillary hemangioma to provide a more meaningful name for all variants of vascular proliferations histori- cally referred to as pyogenic granuloma. Early lesions are indistinguishable from granulation tissue with capillaries and venules distributed radially on the surface of the skin.2
The etiology of pyogenic granulomas is unknown. Predisposing factors can include trauma, hormonal influences, growth fac- tors, infections, and microscopic arteriovenous anastomoses.5 While the evidence is inconsis- tent, approximately 7% of cases have a history of trauma preceding the lesion.4 Oral contracep- tives or hormone changes, particularly in proges- terone levels, during pregnancy might have a role in peripheral vascularization.7 Retinoid therapy for acne (especially isotretinoin) and psoriasis might also be contributing factors.5
Pyogenic granulomas are self-limiting; even dissem- inated lesions tend to resolve within several months without intervention.1-3 Most lesions are treated, how- ever, because they persist for several months and sometimes bleed episodically and profusely.
Management begins with removal of any exacerbating stimulus (eg, oral contraceptives, isotretinoin). Treatment includes cryotherapy, sur- gical excision, shave excision, electrodessication, or pulsed dye laser therapy.1 Pyogenic granulomas tend to recur with conservative treatment and can mani- fest susequently as either solitary lesions or mul- tiple satellites. Recurrence after surgical removal is uncommon. Patients should be reassured that nei- ther the fi rst presentation of a pyogenic granuloma nor recurrence after therapy implies malignancy.
References
1. Sams MW, Lynch PJ. Principles and practice of dermatology. 2nd ed. New York, NY:
Churchill Livingstone Inc; 1996.
2. Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol 1997;37:887-919; quiz 920-2.
3. Taira JW, Hill TL, Everett MA. Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol 1992;27:297-300.
4. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clin- icopathologic study of 178 cases. Pediatr Dermatol 1991;8:267-76.
5. Mooney MA, Janniger CK. Pyogenic granuloma. Cutis 1995;55:133-6.
6. Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma. A study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol 1980;4:470-9.
7. Mussalli NG, Hopps RM, Johnson NW. Oral pyogenic granuloma as a complication of pregnancy and the use of hormonal contraceptives. Int J Gynaecol Obstet 1976;14:187-91.
FOR PRESCRIBING INFORMATION SEE PAGE 96➛
Answer to Dermacase
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