Tiny Lesion Turns Troublesome After Trauma

Four months ago, this 23-year-old man developed a lesion on his right shoulder. It appeared, as he recalls, over the course of a week and has subsequently grown. The lesion, which is now rather large, bleeds copiously with minor trauma. It causes only modest discomfort to the patient but considerable worry to his family.

The lesion was originally tiny and tag-like; the patient initially mistook it for a tick and tried to pull it off. Not only did that fail to work, it also seemed to irritate the lesion. At that point, it started to swell, eventually transforming into the lesion he presents with today.

The patient’s history is otherwise uneventful, and he reports taking no medications. He has had minimal sun exposure but says he tans easily when he does get some sun.

EXAMINATION
The lesion, measuring 5 mm x 2.5 mm, is a dark red and pedunculated papule on the crown of the right shoulder. It looks edematous and feels firm. The patient has otherwise unremarkable type IV skin.

Shave biopsy is performed, using a double-edged razor to make a shallow concave defect under the lesion. The wound is cauterized.

What is the diagnosis?

DISCUSSION
The pathology report confirmed the clinical suspicion of pyogenic granuloma, which, ironically, is neither pyogenic nor granulomatous. The condition acquired this name more than 100 years ago, based on assumptions about its origin. Microscopic examination revealed the highly vascular nature of these lesions, showing a field full of circles that represented the truncated ends of bundles of capillaries and venules. Although they are also called lobular capillary hemangiomas, the term pyogenic granuloma (PG) is still more commonly used.

PGs commonly manifest in the patient’s second or third decade of life, typically on extremities, chest, and nipples. This patient’s story is typical: His lesion began as a tag or wart that he then traumatized, creating a situation in which the body attempts (in vain) to heal the wound. Undisturbed, nearly all PGs would eventually wither and resolve with minimal scarring; however, that process is prolonged when the patient fails to “leave it alone.” (This is especially true in the case of young children.)

While this presentation is characteristic, there are other circumstances in which PGs develop. One is as a consequence of taking certain medications (eg, retinoids, antiretrovirals, and certain chemotherapy drugs). PGs are also commonly seen in the oral cavity of pregnant women in the third trimester and on the end of the umbilical stump in many newborns. Ingrown toenails are another common site; PGs will appear as glistening red, friable buttons of vascular tissue in the perionychial skin adjacent to the affected portion of the nail.

Shave biopsy is standard in such cases, not only to produce a cure but also to establish, via pathologic examination of the tissue, the correct diagnosis. (Nodular melanoma is the most prominent item in the differential; to miss that diagnosis would have dire consequences.) In terms of treatment, mere cautery or cryotherapy will not work and excision is seldom necessary. A deep shave will capture the entire lesion; if any remains, electrodessication and curettage will take care of it. Prior to such procedures, the patient (and family) needs to understand that scarring and pigment loss will occur.

In cases associated with medications or with ingrown toenails, the “cure” would be to withdraw the offending medications—although this is not always advisable for other, obvious reasons.

TAKE-HOME LEARNING POINTS
• Pyogenic granulomas (PG) have nothing to do with infection, nor are they truly granulomatous.

• PGs bleed readily with minor trauma and are often swollen and occasionally painful.

• PGs appear to represent, in most cases, the body’s frustrated attempt to heal a wound, most often a prick or pinch of a pre-existing lesion (eg, tag or mole).

• PGs are also seen in other contexts, such as with use of certain medications or in association with pregnancy.

• If treatment is attempted, the resulting specimen must be submitted for pathologic examination, since other lesions can mimic PGs (of most concern, nodular melanoma).

Four months ago, this 23-year-old man developed a lesion on his right shoulder. It appeared, as he recalls, over the course of a week and has subsequently grown. The lesion, which is now rather large, bleeds copiously with minor trauma. It causes only modest discomfort to the patient but considerable worry to his family.

The lesion was originally tiny and tag-like; the patient initially mistook it for a tick and tried to pull it off. Not only did that fail to work, it also seemed to irritate the lesion. At that point, it started to swell, eventually transforming into the lesion he presents with today.

The patient’s history is otherwise uneventful, and he reports taking no medications. He has had minimal sun exposure but says he tans easily when he does get some sun.

EXAMINATION
The lesion, measuring 5 mm x 2.5 mm, is a dark red and pedunculated papule on the crown of the right shoulder. It looks edematous and feels firm. The patient has otherwise unremarkable type IV skin.

Shave biopsy is performed, using a double-edged razor to make a shallow concave defect under the lesion. The wound is cauterized.

What is the diagnosis?

DISCUSSION
The pathology report confirmed the clinical suspicion of pyogenic granuloma, which, ironically, is neither pyogenic nor granulomatous. The condition acquired this name more than 100 years ago, based on assumptions about its origin. Microscopic examination revealed the highly vascular nature of these lesions, showing a field full of circles that represented the truncated ends of bundles of capillaries and venules. Although they are also called lobular capillary hemangiomas, the term pyogenic granuloma (PG) is still more commonly used.

PGs commonly manifest in the patient’s second or third decade of life, typically on extremities, chest, and nipples. This patient’s story is typical: His lesion began as a tag or wart that he then traumatized, creating a situation in which the body attempts (in vain) to heal the wound. Undisturbed, nearly all PGs would eventually wither and resolve with minimal scarring; however, that process is prolonged when the patient fails to “leave it alone.” (This is especially true in the case of young children.)

While this presentation is characteristic, there are other circumstances in which PGs develop. One is as a consequence of taking certain medications (eg, retinoids, antiretrovirals, and certain chemotherapy drugs). PGs are also commonly seen in the oral cavity of pregnant women in the third trimester and on the end of the umbilical stump in many newborns. Ingrown toenails are another common site; PGs will appear as glistening red, friable buttons of vascular tissue in the perionychial skin adjacent to the affected portion of the nail.

Shave biopsy is standard in such cases, not only to produce a cure but also to establish, via pathologic examination of the tissue, the correct diagnosis. (Nodular melanoma is the most prominent item in the differential; to miss that diagnosis would have dire consequences.) In terms of treatment, mere cautery or cryotherapy will not work and excision is seldom necessary. A deep shave will capture the entire lesion; if any remains, electrodessication and curettage will take care of it. Prior to such procedures, the patient (and family) needs to understand that scarring and pigment loss will occur.

In cases associated with medications or with ingrown toenails, the “cure” would be to withdraw the offending medications—although this is not always advisable for other, obvious reasons.

TAKE-HOME LEARNING POINTS
• Pyogenic granulomas (PG) have nothing to do with infection, nor are they truly granulomatous.

• PGs bleed readily with minor trauma and are often swollen and occasionally painful.

• PGs appear to represent, in most cases, the body’s frustrated attempt to heal a wound, most often a prick or pinch of a pre-existing lesion (eg, tag or mole).

• PGs are also seen in other contexts, such as with use of certain medications or in association with pregnancy.

• If treatment is attempted, the resulting specimen must be submitted for pathologic examination, since other lesions can mimic PGs (of most concern, nodular melanoma).

Four months ago, this 23-year-old man developed a lesion on his right shoulder. It appeared, as he recalls, over the course of a week and has subsequently grown. The lesion, which is now rather large, bleeds copiously with minor trauma. It causes only modest discomfort to the patient but considerable worry to his family.

The lesion was originally tiny and tag-like; the patient initially mistook it for a tick and tried to pull it off. Not only did that fail to work, it also seemed to irritate the lesion. At that point, it started to swell, eventually transforming into the lesion he presents with today.

The patient’s history is otherwise uneventful, and he reports taking no medications. He has had minimal sun exposure but says he tans easily when he does get some sun.

EXAMINATION
The lesion, measuring 5 mm x 2.5 mm, is a dark red and pedunculated papule on the crown of the right shoulder. It looks edematous and feels firm. The patient has otherwise unremarkable type IV skin.

Shave biopsy is performed, using a double-edged razor to make a shallow concave defect under the lesion. The wound is cauterized.

What is the diagnosis?

DISCUSSION
The pathology report confirmed the clinical suspicion of pyogenic granuloma, which, ironically, is neither pyogenic nor granulomatous. The condition acquired this name more than 100 years ago, based on assumptions about its origin. Microscopic examination revealed the highly vascular nature of these lesions, showing a field full of circles that represented the truncated ends of bundles of capillaries and venules. Although they are also called lobular capillary hemangiomas, the term pyogenic granuloma (PG) is still more commonly used.

PGs commonly manifest in the patient’s second or third decade of life, typically on extremities, chest, and nipples. This patient’s story is typical: His lesion began as a tag or wart that he then traumatized, creating a situation in which the body attempts (in vain) to heal the wound. Undisturbed, nearly all PGs would eventually wither and resolve with minimal scarring; however, that process is prolonged when the patient fails to “leave it alone.” (This is especially true in the case of young children.)

While this presentation is characteristic, there are other circumstances in which PGs develop. One is as a consequence of taking certain medications (eg, retinoids, antiretrovirals, and certain chemotherapy drugs). PGs are also commonly seen in the oral cavity of pregnant women in the third trimester and on the end of the umbilical stump in many newborns. Ingrown toenails are another common site; PGs will appear as glistening red, friable buttons of vascular tissue in the perionychial skin adjacent to the affected portion of the nail.

Shave biopsy is standard in such cases, not only to produce a cure but also to establish, via pathologic examination of the tissue, the correct diagnosis. (Nodular melanoma is the most prominent item in the differential; to miss that diagnosis would have dire consequences.) In terms of treatment, mere cautery or cryotherapy will not work and excision is seldom necessary. A deep shave will capture the entire lesion; if any remains, electrodessication and curettage will take care of it. Prior to such procedures, the patient (and family) needs to understand that scarring and pigment loss will occur.

In cases associated with medications or with ingrown toenails, the “cure” would be to withdraw the offending medications—although this is not always advisable for other, obvious reasons.

TAKE-HOME LEARNING POINTS
• Pyogenic granulomas (PG) have nothing to do with infection, nor are they truly granulomatous.

• PGs bleed readily with minor trauma and are often swollen and occasionally painful.

• PGs appear to represent, in most cases, the body’s frustrated attempt to heal a wound, most often a prick or pinch of a pre-existing lesion (eg, tag or mole).

• PGs are also seen in other contexts, such as with use of certain medications or in association with pregnancy.

• If treatment is attempted, the resulting specimen must be submitted for pathologic examination, since other lesions can mimic PGs (of most concern, nodular melanoma).