A pyogenic granuloma, also known as lobular capillary hemangioma, is a common lesion found arising from the skin and mucous membranes. Sometimes it may be difficult to differentiate them from malignancy, clinically or on imaging.
Despite its name, a pyogenic granuloma is not a true granuloma, nor is it pyogenic, in that it does not produce pus 1,2,5,6.
Indeed pyogenic granulomas have had many other monikers over the years probably due to confusion about their true pathological nature. Names used have included Croker and Hartzell disease, pregnancy tumor, fibroangioma, polypoid capillary hemangioma and eruption capillary hemangioma, vascular epulis, and many variations on the granuloma theme such as telangiectatic granuloma (granuloma telangiectacticum), hemangiomatous granuloma, benign pedunculated granuloma (granuloma pedunculatum benignum) and septic granuloma 5,6.
Pyogenic granulomas have an equal incidence across age groups and are more common in women 1,6.
Pyogenic granulomas are usually seen in the head and neck region or the limbs 2. It is the most frequently found focal lesion of the lips, accounting for 48% cases in one series, whilst another study found that they were responsible for 42% of all gingival lesions in children and teenagers 1.
Pyogenic granulomas tend to present as visible painless vascular nodules that may exhibit fast growth 1,8:
- location: head and neck (lips, gums, cheeks, palate, nose, face, but tongue rare), nails, limbs
- size: very variable
- morphology: smooth or lobulated and exophytic
- occasionally a pedunculated growth may result
- color: reddish/bluish hue
- growth: often rapid
Frank bleeding of the lesions is common and is the commonest reason for medical presentation.
Unusual locations include the vulva, penis, esophagus, intestines and tracheobronchial tree. Rarely they may be found arising within blood vessels.
Pyogenic granulomas most commonly arise secondary to a prior injury, often quite trivial, although spontaneous occurrence is also seen, as is growth within a capillary malformation 1. They demonstrate more rapid growth in the presence of female hormones, which is thought to explain their commonality in pregnancy 1.
The International Society for the Study of Vascular Anomalies (ISSVA) classification, updated in 2018, includes soft tissue vascular lesions 3.
These lesions have been characterized on ultrasound, CT and MRI 1,2.
Pyogenic granulomas are usually poorly-marginated, ellipsoid, hypoechoic lesions, commonly subcutaneous in location. Profuse intralesional vascularity - both central and peripheral - is often present on color Doppler ultrasound (although poor peripheral flow is also sometimes seen) 2.
Cross-sectional imaging characteristics tend to be that of a soft tissue lesion with marked contrast enhancement, although enhancement may be non-uniform 2,4.
Treatment and prognosis
Most pyogenic granulomas are surgically removed which evidence shows has the least risk of recurrence 1. A panoply of other therapy modalities are employed when for whatever reason standard excision is not felt to be the best option, including curettage, electrocautery, radio- and cryosurgery, laser and sclerotherapy.
Occasionally satellitosis occurs, which is the eruption of multiple pyogenic granulomas following the resection of the original lesion 8.
History and etymology
Pyogenic granuloma was originally called botryomycosis hominis when it appeared in an article in 1897 by Poncet and Dor. In 1904 Crocker and MB Hartzell coined the term pyogenic granuloma which became its (near) ubiquitous monicker 6.
- 1. Wollina U, Langner D, França K, Gianfaldoni S, Lotti T, Tchernev G. Pyogenic Granuloma - A Common Benign Vascular Tumor with Variable Clinical Presentation: New Findings and Treatment Options. (2017) Open access Macedonian journal of medical sciences. 5 (4): 423-426. doi:10.3889/oamjms.2017.111 - Pubmed
- 2. Cantisani V, Del Vecchio A, Fioravanti E, Romeo U, D'Ambrosio F. Color-Doppler US features of a pyogenic granuloma of the upper dorsum tongue. (2016) Journal of ultrasound. 19 (1): 67-70. doi:10.1007/s40477-014-0121-6 - Pubmed
- 3. Brahmbhatt AN, Skalski KA, Bhatt AA. Vascular lesions of the head and neck: an update on classification and imaging review. (2020) Insights into imaging. 11 (1): 19. doi:10.1186/s13244-019-0818-3 - Pubmed
- 4. Lee G, Suh K, Lee Y, Kang I. CT findings in two cases of lobular capillary haemangioma of the nasal cavity: focusing on the enhancement pattern. (2012) Dento maxillo facial radiology. 41 (2): 165-8. doi:10.1259/dmfr/85015314 - Pubmed
- 5. Subramanyam RV. Misnomers in oral pathology. (2010) Oral diseases. 16 (8): 740-6. doi:10.1111/j.1601-0825.2010.01695.x - Pubmed
- 6. Bafna Y, Kambalimath HV, Khandelwal V, Nayak PA. Management of unusual case of Crocker and Hartzell's disease in a young patient with a 1 year follow-up. (2013) BMJ case reports. doi:10.1136/bcr-2013-009913 - Pubmed
- 7. Gomes SR, Shakir QJ, Thaker PV, Tavadia JK. Pyogenic granuloma of the gingiva: A misnomer? - A case report and review of literature. (2013) Journal of Indian Society of Periodontology. 17 (4): 514-9. doi:10.4103/0972-124X.118327 - Pubmed
- 8. Bugshan A, Patel H, Garber K, Meiller TF. Alternative Therapeutic Approach in the Treatment of Oral Pyogenic Granuloma. (2015) Case reports in oncology. 8 (3): 493-7. doi:10.1159/000441839 - Pubmed