An 8-year-old Caucasian girl presented with a 4-week history of an enlarging papule on the left lower eyelid. The area began as a pinpoint papule that was thought to be a scratch. There was no other history of preceding trauma. The child was asymptomatic. The papule was not painful and had never bled. It was enlarging rapidly.
Physical examination revealed a 7-mm slightly pedunculated deep red papule on the left lower eyelid (see image above). No other physical findings were noted.
A pyogenic granuloma is the most common acquired vascular tumor of the skin and mucous membranes in children and young adolescents. It also is seen with increased frequency in women during pregnancy.
Typically, lesions present as small bright-red papules that rapidly enlarge over days to weeks to form slightly pedunculated or sessile nodules. Careful examination of the base of the growing papule often reveals a collarette of peripheral scale. The epidermis overlying these lesions is very fragile, and even minor trauma can result in superficial ulcération and bleeding. Bleeding is brisk, and direct pressure for 5 to 10 minutes usually is required for cessation. This is what typically brings patients to medical attention. After bleeding, the papule often is crusted and may be difficult to recognize. Without treatment, regrowth generally occurs over several weeks.
The cause of pyogenic granuloma is unknown. Lesions typically occur on body areas that are most subject to trauma, such as the face, fingers, and forearms (Figure). Lesions can, however, be seen on any body location, including the mucosal surfaces of the mouth or on the shaft of the penis.1 These are not infectious, nor do they demonstrate granuloma formation on histopathologic examination, despite the name. Pathologic examination, which is usually done to confirm the diagnosis, reveals histology similar to that of a well-circumscribed infantile hemangioma, with endothelial cell proliferation and increased vascular channels.
Figure. Pyogenic granuloma lesions typically occur on body areas that are most subject to trauma, such as the face, fingers, and forearms.
The differential diagnosis of this rapidly growing papule includes a hemangioma, a Spitz or spindle cell nevus, or an amelanotic melanoma. Lesions are rare in the first year of life, although they can occur. Any lesion with onset after age 6 months cannot be a hemangioma, as hemangioma of infancy has its onset within weeks of birth. Spitz nevi and amelanotic melanoma comprise atypical melanocytes rather than endothelial cells. They also grow rapidly and occur in similar locations in children. The typical growth phase for one of these lesions is growth to a 6- to 8-mm size over a 6month period, however, rather than the 3-week period that is typical of a pyogenic granuloma. In addition, bleeding is unusual in these lesions.
Treatment for a pyogenic granuloma is shave excision with electrodesiccation to help prevent recurrence. Excision may be required for lesions in certain locations, such as eyelids or mucosa, to reduce the risk of recurrence. Pulsed dye laser can be effective if lesions are treated early,2 and continuous wave/pulsed carbon dioxide laser has also been used effectively.3
1. Naimer S A, Cohen A, Vardy D. Pyogenic granuloma of the penile shaft following circumcision. Pediatr Dermatiti. 2002;19(1):3941.
2. Tay YK, Weston WL, Morelli JG. Treatment of pyogenic granuloma in children with the flashlamp-pumped pulsed dye laser. Pediatrics. 1997;99(3): 368-370.
3. Raulin C, Greve B, Hammes S. The combined continuous wave/pulsed carbon dioxide laser for treatment of Pyogenic granuloma. Arch Dermaiol. 2002;138(l):33-37.