Clinical Challenge: Bleeding Nodule on Chest

Pyogenic granuloma (PG) is an acquired benign vascular tumor of the skin or mucous membranes that most commonly arises on the head and neck followed by the trunk and upper extremities.1 The name is a misnomer as lesions are neither pyogenic...

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Pyogenic granuloma (PG) is an acquired benign vascular tumor of the skin or mucous membranes that most commonly arises on the head and neck followed by the trunk and upper extremities.¹ The name is a misnomer as lesions are neither pyogenic nor granulomas.² The condition predominately affects children and young adults with no predilection by sex. A characteristic lesion presents as a solitary, painless, red to bluish-black papule or nodule. Dermoscopy reveals homogeneous reddish or white-red areas surrounded by a whitish collarette.³ A well-circumscribed proliferation of capillaries in a lobular pattern is noted on histology.

The condition may arise during pregnancy, typically after the first trimester. When occurring on the oral mucosa, the lesions are called granuloma gravidarum.⁴ Causation may be related to hormonal alterations. Increased estrogen induces secretion of cutaneous wound healing factors as well as vascular endothelial growth factors.⁵ These stimulatory proteins are thought to trigger proliferation of vascular tissue either in response to minor trauma or spontaneously.⁶

Most patients seek treatment because of recurrent bleeding episodes. A treatment plan should take into consideration lesion location as well as aesthetic concerns among patients. Surgical excision has a low recurrence rate in comparison to curettage with cautery, although the latter may heal with less scarring.⁷ Additional treatment options include cryotherapy, laser, and sclerotherapy.⁸ Topical timolol is another noninvasive option with variable success rates.⁹

Stephen Schleicher, MD, is director of the DermDox Dermatology Centers, associate professor of medicine at Geisinger Commonwealth Medical College, and clinical instructor of dermatology at Arcadia University and Kings College.

References

1. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermato. 1991;8(4):267-276. doi:10.1111/j.1525-1470.1991.tb00931.x

2. Higgins JC, Maher MH, Douglas MS. Diagnosing common benign skin tumors. Am Fam Physician. 2015;92(7):601-607.  

3. Jha AK, Sonthalia S, Khopkar U. Dermoscopy of pyogenic granuloma. Indian Dermatol Online J. 2017;8(6):523-524. doi:10.4103/idoj.IDOJ_389_16

4. Purwar P, Dixit J, Sheel V, Goel MM. ‘Granuloma gravidarum’: persistence in puerperal period an unusual presentation. BMJ Case Rep. 2015;2015:bcr2014206878. doi:10.1136/bcr-2014-206878

5. Kanda N, Watanabe S. Regulatory roles of sex hormones in cutaneous biology and immunology. J Dermatol Sci. 2005;38(1):1-7. doi:10.1016/j.jdermsci.2004.10.011

6. Katta R, Bickle K, Hwang L. Pyogenic granuloma arising in port-wine stain during pregnancy. Br J Dermatol. 2001;144(3):644-645. doi:10.1046/j.1365-2133.2001.04114.x

7. Gilmore A, Kelsberg G, Safranek S. Clinical inquiries: what’s the best treatment for pyogenic granuloma? J Fam Pract. 2010;59(1):40-42.

8. Sarwal P, Lapumnuaypol K. Pyogenic granuloma. In: StatPearls [Internet]. StatPearls Publishing; 2022.

9. Gupta D, Singh N, Thappa DM. Is timolol an effective treatment for pyogenic granuloma? Int J Dermatol. 2016;55(5):592-595. doi:10.1111/ijd.13237