A young girl is brought in by her mother to see their pediatrician for a red growth on the face that has been there for two months (Figure 142-1). The red growth bleeds easily if traumatized. The pediatrician recognizes the typical features of a pyogenic granuloma and presents various treatment options to the mother including excision with biopsy. It is clear that the child will not stay still for local anesthetic with the needle but is willing to allow the physician to use a Cryo Tweezer to freeze the pyogenic granuloma. The pediatrician places the Cryo Tweezer in liquid nitrogen and applies the device to the pyogenic granuloma. As the child is cooperative with the procedure a second freeze is performed in the same manner. On follow-up visit in 3 weeks, the pyogenic granuloma is gone. The mother is warned if there is regrowth to return for further evaluation and treatment.

Pyogenic granuloma (PG) is the name for a common, benign, acquired, vascular neoplasm of the skin and mucous membranes.

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  The term “lobular capillary hemangioma” is an accepted and preferred term because PG is neither pyogenic (purulent bacterial infection) nor a granuloma.¹ We continue to use “pyogenic granuloma” as this is still the most recognized term.

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  Most often seen in children and young adults (0.5% of children’s skin lesions); 42 percent of cases occur by 5 years of age and about 1 percent are present at birth.¹

  
  
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  Oral lesions occur most often in the second and third decade, more commonly in women (2:1).1 In a case series from Israel of pediatric gingival lesions (N = 233), one-quarter were PGs.

  
  
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  Also common during pregnancy.

  
  
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  PG has also been reported in the gastrointestinal tract, the larynx, and on the nasal mucosa, conjunctiva, and cornea.

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  Etiology is unknown but may be the result of trauma, infection, or preceding dermatoses.

  
  
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  Consists of dense proliferation of capillaries and fibroblastic stroma that is infiltrated with polymorphonuclear leukocytes.

  
  
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  Multiple PGs have been reported at burn sites and following use of oral contraceptives, protease inhibitors, and topical application of tretinoin for acne.²

  
  
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  PGs are known to regress following pregnancy. Vascular endothelial growth factor (VEGF) was found in one study to be high in the granulomas in pregnancy and was almost undetectable after parturition and associated with apoptosis of endothelial cells and regression of granuloma.³

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  Trauma (up to 50%), including nose piercing,⁴ or chronic irritation (e.g., orthodontic appliance).^{1, 5}

  
  
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  Multiple lesions can follow manipulation of a primary lesion.⁶

  
  
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  Pregnancy or use of oral contraceptives for oral PGs; postulated due to imbalance between angiogenesis enhancers and inhibitors.¹

  
  
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  Infection with Bartonella.¹

Clinical Features

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  Usually solitary, erythematous, dome-shaped papule or nodule that bleeds easily (Figures 142-1 to 142-6); rarely causes anemia. Satellite lesions may rarely occur.

  
  
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  Prone to ulceration, erosion, and crusting.

  
  
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  Size ranges from a few millimeters to several centimeters (average size is 6.5 mm).¹

  
  
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  Rapid growth over a period of weeks to maximum size.

  
  
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  Variants include cutaneous, oral mucosal (granuloma gravidarum), satellite, subcutaneous, intravenous, and congenital types.1

  
  
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  PG can also arrive within port-wine stains (PWS); in one case series (N = 31 with nodules arising within PWS), 14 biopsy specimens were PGs.⁷ Most PGs and arteriovenous malformations (10 specimens) occurred in the area innervated by the second branch of the trigeminal nerve. In one case series, PGs arising with PWS were seen as a complication of 595 nm tunable pulsed dye laser treatment of the original lesion.⁸