Clinical Challenge: Red Papule Following Puncture by Rose Thorn - MPR

Clinical Challenge: Red Papule Following Puncture by Rose Thorn

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A 58-year-old woman sought consultation in an emergency department because of a lesion on her finger that arose shortly after it was punctured by the thorn of a rose while gardening. Treatment with ciprofloxacin was initiated, but the site did not resolve and would bleed spontaneously. She denied fever, malaise, and elevated temperature.

Examination of the affected area revealed a 0.3cm erythematous papule. No other lesions were noted, and axillary lymph nodes were nonpalpable. Given the history of puncture by a rose thorn, early sporotrichosis was entertained, and treatment with oral itraconazole was initiated. The patient returned in 10 days, reporting that the intermittent episodes of bleeding had continued. On closer inspection, the lesion appeared more friable.

A shave biopsy with electrodessication of the base was performed, and histopathology revealed a pyogenic granuloma, a benign vascular tumor of the skin.This tumor occurs in both males and females of all ages and is most commonly located on the...

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A shave biopsy with electrodessication of the base was performed, and histopathology revealed a pyogenic granuloma, a benign vascular tumor of the skin.

This tumor occurs in both males and females of all ages and is most commonly located on the head and neck.1,2 While the underlying cause of pyogenic granulomas is unknown, trauma, as demonstrated by this case, is an inciting factor in about 7-23% of patients.2,3


The lesion usually begins as a small red papule that may enlarge over several days to weeks until it spontaneously stabilizes in size. It can be pedunculated or sessile and will bleed with minor trauma necessitating treatment.

Histopathology will reveal capillaries in a lobular arrangement.4 The specimen may also demonstrate an overlying atrophic or ulcerated epidermis and nonspecific changes such a capillary dilation, stromal edema, granuloma, and inflammation.2,4

Full excision of larger lesions is curative; curettage and electrocautery and shave excision are also effective, although recurrence is not unusual.5

Megha D. Patel is a student at the Commonwealth Medical College, Scranton, PA.

Stephen Schleicher, MD, is an associate professor of medicine at the Commonwealth Medical College and an adjunct assistant professor of dermatology at the University of Pennsylvania Medical College. He practices dermatology in Hazleton, PA.

References

  1. Harris MN, Desai R, Chuang TY, Hood AF, Mirowski GW. Lobular capillary hemangiomas: An epidemiologic report, with emphasis on cutaneous lesions. J Am Acad Dermatol. 2000;42(6):1012-1016.
  2. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): A clinicopathologic study of 178 cases. Pediatr Dermatol. 1991;8(4):267-276.
  3. Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol. 2004;21(1):10-13.
  4. Mills S, 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(5):470-479.
  5. Giblin AV, Clover AJ, Athanassopoulos A, Budny PG. Pyogenic granuloma—the quest for optimum treatment: Audit of treatment of 408 cases. J Plast Reconstr Aesthet Surg. 2007;60(9):1030-1035.