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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.

Klasifikasi: granuloma piogenik dengan satellitosis, [5, 6, 7]

granuloma piogenik intravena,[8]

granuloma piogenik subkutan,[9, 10]

dan

granuloma piogenik erupsi.[11, 12, 13]

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

lainnya. [14, 15] Sebuah reaksi oksida mekanisme sintesis nitrat diduga

berkontribusi terhadap angiogenesis dan percepatan pertumbuhan dari
http://refimgshow%288%29/http://refimgshow%288%29/


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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

menyebabkan perdarahan yang signifikan[16, 17, 18]

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 adalah3:2.[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 muncullebih 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


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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 varianbiasa. 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 humanimmunodeficiency 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]


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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 selamakehamilan 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]


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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

pada granuloma piogenik[43]

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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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 capillaryhemangioma.[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.
http://emedicine.medscape.com/article/1255694-overviewhttp://refimgshow%281%29/http://emedicine.medscape.com/article/1255694-overview


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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.
http://refimgshow%283%29/http://refimgshow%283%29/http://refimgshow%282%29/http://refimgshow%282%29/http://refimgshow%281%29/


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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.
http://refimgshow%288%29/http://refimgshow%288%29/http://refimgshow%288%29/http://refimgshow%285%29/http://refimgshow%285%29/http://refimgshow%284%29/http://refimgshow%284%29/


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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]

RaceNo 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]


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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 diagnosisof 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 duringor 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


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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 decreasingfrequency, 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.


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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-2were 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
http://emedicine.medscape.com/article/219110-overviewhttp://emedicine.medscape.com/article/965086-overviewhttp://emedicine.medscape.com/article/965086-overviewhttp://refimgshow%289%29/http://refimgshow%289%29/http://emedicine.medscape.com/article/965086-overviewhttp://emedicine.medscape.com/article/965086-overviewhttp://emedicine.medscape.com/article/219110-overview


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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 ofthe 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
http://refimgshow%289%29/


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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) appliedto 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 acquiredimmune 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]


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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 lesionSuperficial 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.


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Rarely, a rapidly growing large tumor may produce significant

hemorrhage.

Prognosis

Prognosis is excellent after simple removal and wound care.


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