Granuloma pyogenicum L98.0

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

angioma eruptives; angioma proliferating; Botryomycosis; Botryomykom; eruptive angioma; Eruptive hemangioma; Granuloma pediculatum; Intravenous pyogenic granuloma; Lobular capillary hemangioma; Nail fold angiomatosis; Peduncle tubers; Pregnancy tumor; proliferating angioma; Pseudobotryomykom; pyogenic granuloma; teleangiectatic granuloma

History
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Dor and Poncet, 1897

Definition
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More frequent, mostly after trauma, but also spontaneously developing, rapidly exophytic, benign, rapidly growing vascular tumor.

Classification
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Clinical and histological classification:

  • Classical Granuloma pyogenicum
  • Epulis gravidarum of the gingiva
  • Subcutaneous and intravascular granuloma pyogenicum (histological diagnosis)
  • Disseminated (eruptive) Granuloma pyogenicum (multiple small mostly aggregated nodules)
  • Granuloma pyogenicum with satelliteosis (especially in children and young adults; recurrent tumor with synchronous shooting of multiple satellite nodules)

Etiopathogenesis
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Banal injury with subsequent development of an overflowing, vascular granulation tissue; more common during pregnancy. Apparently, BRAF and RAS mutations play a role in the pathogenesis of this reactive tumor.

Manifestation
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Common during pregnancy (epulis gravidarum of the gingiva) with postpartum involution.

age of first manifestation: rare in the first year of life; most common in the 2nd-5th decade of life

Localization
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Mainly lips, scalp, face, fingertips, tongue, palm and toes, more rarely are localizations in the area of the oral mucosa.

Clinical features
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  • 1.0-3.0 cm large, rarely larger, solitary, soft, spherical, slightly bleeding, red, blue or black, sharply defined papules (nodes).
  • Usually absent to slight pain.
  • With increasing growth there is usually a constriction of the base, bordered by the epidermis like a collar. The surface is often eroded, later ulcerated and covered with a black crust.
  • The "uncomplicated" granuloma pyogenicum is distinguished from the (rare) bacterial nail fold angiomatosis, which is more likely to be attributed to the reactive granulation tissue in Unguis incarnatus.
  • The lobular capillary hängiomas of the type Granuloma pyogenicum also include the rare eruptive, disseminated cases (satelliteosis), which can occur after incomplete removal of the "primary tumour". Osseous destructions have also been described. In this respect, the dignity of this rare form of manifestation remains questionable.

Histology
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Exophytic, multilobularly structured, ripe cell (CD31+) capillary tumor in the papillary and reticular dermis. Missing or only thin epithelial coating. Numerous small or larger vascular spaces with erythrocyte clusters. In the upper parts of the tumour there is often a strong, inflammatory accompanying reaction with neutrophil granulocytes and lymphocytes in edematous connective tissue stroma. In sections, especially in the deeper parts, also solid tumour nodes with only a few vascular spaces. Numerous mitoses (Ki-67 positivity is significantly increased), moderate endothelatypia. In late stages widened septa with receded vascular parenchyma.

Diagnosis
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The clinical picture is diagnostic.

Differential diagnosis
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Malignant melanoma; angiosarcoma. In multifocal, eruptive occurrence the epithelioid hemangiodendothelioma must be excluded.

Complication(s)
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A recurrence after incomplete removal may occur. Satelliteosis is rare.

Therapy
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Excision without safety distance under local anesthesia, histological examination to exclude malignancy. Possibly also treatment attempt with Neodymium-YAG-Laser and CO 2 -Laser. As there is a risk of recurrence in ablative procedures, this treatment option is not recommended!

Progression/forecast
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Great tendency to ulceration and bleeding tendency. Untreated, the granuloma pyogenicum can shrink after a few months. A soft fibromatous papule remains as a relic. The recurrence rate after incomplete removal is high.

Literature
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  1. Baran R (2002) Pyogenic granuloma-like lesions associated with topical retinoid therapy. J Am Acad Dermatol 47: 970
  2. Exner V et al (2001) Sebaceous gland carcinoma of the neck. dermatologist 52: 147-149
  3. Groesser L et al (2016) BRAF and RAS Mutations in Sporadic and Secondary Pyogenic Granuloma. J Invest Dermatol 136:481-486.
  4. Holbe HC et al (2003) Surgical pearl: ligation of the base of pyogenic granuloma--to atraumatic, simple, and cost-effective procedure. J Am Acad Dermatol 49: 509-510
  5. Kocer U et al (2003) Intravenous pyogenic granuloma of the hand. Dermatol Surgery 29: 974-976
  6. Mazereeuw mammal J (2003) Pyogenic granuloma within unilateral dermatomal superficial telangiectasia. Br J Dermatol 148: 823-824
  7. Mensch A et al. (2007) Multifocal eruptive epitheloid cell hemangioma of the lobular capillary type (granuloma-teleangiectaticum type). derm 13: 124-128
  8. Musumeci ML et al (2013) Two pediatric casesof pyogenic granuloma treated with imiquimod 5% cream: combined clinical and
  9. dermatoscopic evaluation and review of the literature. G Ital Dermatol Venereol 148:147-152
  10. Poncet et Dor A (1897) De la Botryomycose humaine. Rev the surgeon (Paris) 18: 996-997
  11. Purwar P et al (2015) 'Granuloma gravidarum': persistence in puerperal period an unusual presentation. BMJ Case Rep 9 doi: 10.1136/bcr-2014-206878
  12. Raulin C et al (1997) Granuloma pyogenicum--removal with the CO2 laser. dermatologist 48: 402-405
  13. Raulin C et al (2002) The combined continuous-wave/pulsed carbon dioxide laser for treatment of pyogenic granuloma. Arch Dermatol 138: 33-37
  14. Taira JW et al (1992) Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol 27: 297-300

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Last updated on: 29.10.2020