Definition

Pyogenic granuloma is a benign vascular tumor that develops in tissues like the skin and mucous membranes, such as those in the mouth. Though rare, it can also be found in the digestive tract. Another term for pyogenic granulomas is lobular capillary hemangiomas.

In pregnant women, pyogenic granuloma that occurs on the mucous membranes of the mouth is referred to as pregnancy granuloma, granuloma gravidarum, or epulis gravidarum. It typically appears in the second or third trimester. This tumor takes the form of a small, smooth red lump that bleeds easily due to the high concentration of blood vessels within it. Pyogenic granuloma is generally not associated with infection, as the lump contains no white blood cells or pus.

Causes

Although the precise cause of pyogenic granuloma is still unknown, several factors are believed to contribute to its development. These include a history of previous infections and existing abnormalities in the blood vessels.

Pyogenic granulomas often occur following minor injuries to the hands, arms, or face, triggering an inflammatory response in the tissue. However, research shows that only 7% of pyogenic granuloma cases are associated with a history of injury.

Other possible triggers include:

1. Hormonal Factors
   Hormonal changes, especially during pregnancy, are believed to play a role in the development of pyogenic granuloma. The condition becomes more prevalent in women during pregnancy, possibly due to the effects of estrogen and other sex hormones, which may provoke an exaggerated inflammatory response in gum tissue, leading to the formation of lumps in the mouth.
2. Medications
   Certain medications have been linked to the development of pyogenic granuloma, with studies indicating that nearly 30% of cases are associated with drug use. The medications most often implicated include:

• Retinoid-containing drugs, which have been linked to widespread pyogenic granuloma (although this is very rare), especially in patients using isotretinoin for severe cystic acne
• Antiretroviral drugs (ARVs), such as indinavir, used in the treatment of HIV/AIDS
• Antineoplastic drugs administered to cancer patients
• Drugs that suppress the immune system

Risk Factor

Pyogenic granuloma can affect individuals of all ages but is more common in children and pregnant women. Epidemiological studies have produced conflicting results regarding the disease’s patterns. In one study conducted on children, the average age of affected individuals was 6 to 10 years, with a slight preference for males. Other studies have shown a male-to-female ratio of 1:1.2, where males are more likely to develop the condition at a younger age, while female patients are generally diagnosed between the ages of 30 and 40.

Symptoms

Pyogenic granuloma initially manifests as a small, solid, reddish lump, with occasional multiple lumps forming around it. Though rare, these lumps may spread across the body. 

Over time, the lumps may undergo rapid changes, growing quickly over several weeks or months, often developing a stalk. The characteristics of these lumps include:

• Typically stable in size, measuring from several millimeters to centimeters
• Color ranges from reddish to reddish-brown or purplish
• Circular scaling may occur at the base of the lump
• Tendency to bleed easily

Due to the presence of numerous blood vessels, the surface of the granuloma is fragile and bleeds easily, even from minor injuries. This bleeding tends to recur frequently and may be challenging to control. In rare instances, the surface may ulcerate, leading to open sores.

Pyogenic granuloma can appear on any normal skin or mucous membrane. Commonly affected areas include:

• Body
• Upper arms
• Head
• Neck
• Legs
• Feet
• Lips
• Gums
• Tongue
• Nasal mucous membranes
• Eye viscera
• Cervix
• Vagina

In pregnant women, the most frequent locations are the inner cheeks and gums. Though rare, the digestive tract may also be involved, possibly leading to asymptomatic presentations or occult bleeding, which can result in anemia. In certain cases, pyogenic granulomas develop under the skin or in blood vessels, appearing as subcutaneous lumps with well-defined boundaries.

Diagnosis

To diagnose pyogenic granuloma, a physician will inquire about your medical history and symptoms, followed by a physical examination. In some cases, a dermoscopic examination may be conducted. If the diagnosis remains uncertain, a skin biopsy may be recommended to confirm the condition and rule out other potential diseases, such as skin cancer. This biopsy involves removing a tissue sample, which is then examined in a laboratory. In some cases, the entire lump may be removed during the biopsy procedure for further examination.

Management

Since pyogenic granulomas are prone to bleeding, wounds, and ulceration, they often require treatment. Treatment efficacy and the likelihood of recurrence vary. Regardless of the method, recurrence remains a possibility.

Small pyogenic granulomas may resolve spontaneously, but larger lumps generally necessitate treatment. Treatment options include:

• Total excision surgery involves the complete removal of the granuloma, typically performed in less visible areas, with a low risk of recurrence.
• Curettage followed by electrocauterization: this electrical surgery option is suitable for facial lumps; it destroys the granuloma but has a higher recurrence rate.
• Chemical cauterization involves using a silver nitrate solution or cryotherapy (freezing therapy).
• Laser therapy is another option for treating the lumps.

Drug therapy is generally not recommended. Although various topical or injectable medications may be applied directly to the lump, their efficacy varies. In cases involving pregnancy or drug-induced pyogenic granulomas, the recurrence rate after therapy is higher. If a medication is suspected of causing the lump, it should be discontinued unless it is vital for conditions like cancer, where treatment cannot be stopped.

Most pyogenic granulomas can be surgically removed, although scarring may occur post-procedure. Recurrence is likely if the entire lump is not excised, and in such cases, total excision is preferred.

Complications

Potential complications from pyogenic granuloma include:

• Bleeding
• Ulceration
• Infection
• Recurrence
• Cosmetic concerns, which can be a source of psychological distress, especially when the lump is on the face

Prevention

While the exact cause of pyogenic granuloma remains unknown, it is linked to several factors. To reduce the risk of developing pyogenic granuloma, consider:

• Avoiding or discontinuing medications associated with the condition
• Avoiding skin injuries, such as piercings
• Maintaining oral hygiene
• Cleaning and covering wounds to prevent infection

When to See a Doctor?

If you notice a lump on your skin that bleeds easily, it is advisable to consult a doctor or dermatologist for appropriate diagnosis and treatment.

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