Pyogenic granuloma is a benign neoplasm of the skin or mucous membranes of vascular nature. Externally, it is a rounded formation (papule) with a diameter of up to 1.5 centimeters of bright red, cherry or black-brown color. The volume of the tumor is filled with small vessels and capillaries surrounded by connective tissue. The surface is easily injured and bleeds profusely. External examination, dermatoscopy, and histological examination data help the doctor determine the type of neoplasm. If the seal does not undergo reverse development spontaneously, surgical treatment (electro-, cryo- or laser coagulation) is indicated.
ICD 10
L98.0 Pyogenic granuloma
General information
In practical dermatology, pyogenic granuloma occurs under the name botryomycoma, telangiectatic granuloma, granulation-type hemangioma, eruptive angioma. Connective tissue forms layers inside the tumor node, which determines the most appropriate definition of pathology from the point of view of histology “lobular capillary hemangioma”. It occurs in adolescents, adults under 30 years of age. It is equally often diagnosed in patients of both sexes. Hormonal changes cause frequent development of the disease in pregnant women (about 5% of cases). Cases of multiple botryomycoma, its subcutaneous or submucosal location, the formation of vascular formations on the inner surface of the esophagus and intestines are described.
Causes
The etiology of the disease is not fully understood. The assumptions about the mycotic genesis of pathology expressed in the XIX century were not confirmed in the future. Theories according to which the disease has an inflammatory or viral nature proved to be untenable. Now botryomycoma is classified as an angioma developing as a reactive process at the site of microtrauma. In the genesis of the disease , the main importance is:
- Mechanical damage to mucous membranes and skin. The leading factor in the development of the disease. This is evidenced by the localization of neoplasms on the most prone to injury and micro-injury areas of the body: fingers, feet, lips, gums, nasal and oral mucosa. To start the formation of granuloma, a minor impact is sufficient: a prick, splinters, careless treatment of the cuticle of the nail.
- Hormonal imbalance. According to statistics, most cases of vascular neoplasms are detected in adolescents, pregnant women. A significant provoking factor is the use of hormonal contraceptives, endocrine pathology. It is important to increase the greasiness of the skin under the influence of hormones and its excessive degreasing during puberty, an increase in the level of vascular growth factor in pregnant women.
- Medicinal effect. The likelihood of granulation hemangioma increases when taking protease inhibitors, some antiviral drugs, retinoids used to treat acne. Drugs of both systemic (in tablets, capsules, injections) and local action (creams, lotions, ointments) are important.
- Skin diseases. Patients with dermatoses, flaming nevus, telangiectatic angioma suffer from botryomycoma more often than people without dermatological problems. Multiple lesions develop at the site of thermal and chemical burns. Irritation of the mucous membrane of the cornea and conjunctiva with chemicals, intolerance to certain components of cosmetics, conjunctivitis and blepharitis can cause the appearance of vascular papules on the eyelids. Giant granulomas develop in bedridden patients in places of bedsores.
Pathogenesis
The basis of papule development is the reactive growth of granulation tissue under the influence of external and internal influences. Granulations consist of newly formed vessels and connective tissue, provide rapid wound healing. They create conditions for the subsequent epithelization of the wound surface, the formation of a scar. Granuloma is a consequence of a violation of the normal process of granulation formation, excessive vascular development, active division of fibroblasts, excessive production of connective tissue fibers in trauma. The normal thickness of the granulation layer is 1-2 mm. The diameter of the pathological formation can reach one and a half centimeters.
The development of pyogenic granuloma largely repeats the process of wound healing. The papule consists of arterioles, venules, capillaries, a small number of fibroblasts, connective tissue fibers. The longer the neoplasm exists, the more connective tissue becomes in it. The final stage is pronounced fibrosis of the papule, accompanied by epithelization of its surface.
Symptoms
In 75% of cases, the growth of the node begins on unchanged skin. Microtraumas that can lead to the appearance of botryomics often go unnoticed by the patient. In addition to the fingers and oral mucosa, papules can appear on the skin of the face, the back of the hands, palms, neck, chest, upper back. In pregnant women, seals are formed mainly on the gum mucosa of the upper jaw, the inner surface of the lips.
Papula grows for several weeks. The maximum diameter is 1.5 cm, the average is 6 mm. It has a rounded or lobed shape, rich color due to a large number of vessels, a wide base, less often a short leg. The consistency is soft, elastic. The surface of the papule is easily injured, often eroded or covered with crusts, may be surrounded by a white border of exfoliated epithelium. The node is painless, because it has no nerve endings. Discomfort is caused by the presence of a protruding formation on the arms, neck, shoulders and other parts of the body, which clings to clothes, objects, and gives profuse bleeding when damaged. Botryomycoma in the area of the nail bed during active growth can peel off the nail plate.
Having reached a certain size, the papule begins to gradually thicken due to the active development of connective tissue layers up to complete fibrosis. Thrombosis, desolation of blood vessels lead to focal necrosis of pyogenic granuloma. When the causal factor is eliminated, education can disappear on its own. The reverse development of granuloma may take several months.
Complications
The only significant complication of pyogenic granuloma is profuse bleeding, which opens when the seal is damaged. With a prolonged outflow of blood from multiple nodes, the patient is at risk of developing anemia. With external localization of formations, the source of blood loss can be easily established. It can be much more difficult to suspect bleeding from the gastrointestinal tract. Difficulties may cause differential diagnosis of botryomycoma and bleeding ulcers of the stomach or intestines.
Diagnostics
Benign pyogenic granuloma must be distinguished from a number of other pathological formations. Here, the appearance of the node, its microscopic structure, and any other data that help the dermatologist to make an accurate diagnosis are crucial: the growth rate of the neoplasm, the presence of provoking factors, the effectiveness of previous treatment, concomitant diseases. Valuable information allows you to get:
- Dermatoscopy. Examination of the papule using dermatoscopy allows you to identify signs characteristic of angiomatous neoplasm (a homogeneous node of reddish color surrounded by a white corolla). As a rule, visual signs are sufficient for differential diagnosis of the disease with a number of benign and malignant pathological changes in the skin, outwardly similar to botryomycoma.
- Node biopsy. Tissue sampling for histological examination is often carried out right during the operation to remove the neoplasm. This allows you to confirm the diagnosis of botryomycoma, determine the scope of surgical intervention. Pathomorphological examination determines the proliferation of capillaries and fibroblasts, infiltration of the stroma by leukocytes.
Complex diagnostic cases may require examination by a dermatologist, surgeon. Botryomycoma looks like pigmented melanoma, squamous cell carcinoma of the skin, skin metastases of tumors of bones, internal organs, and a number of other malignant neoplasms. The location of foci between the shoulder blades may be one of the manifestations of Hodgkin’s disease, which requires the attention of a hematologist.
Pyogenic granuloma treatment
Medical tactics in relation to neoplasms are determined by a number of factors: the age of existence, location, profusion of bleeding, the presence of pregnancy in a woman. Periodically, the bleeding node of the finger will have to be removed immediately to make it easier for the patient to perform everyday tasks. The formation of the oral mucosa, which appeared during pregnancy, is recommended to be observed several months after childbirth. If the pyogenic granuloma does not regress spontaneously, it is removed during a small outpatient operation. Surgical treatment methods include:
- Electrocoagulation. It allows you to remove pathologically altered tissues quickly, with minimal blood loss. The probability of recurrence of botryomycoma after electrocoagulation is lower compared to other surgical methods. Anesthesia with the use of local anesthetics is mandatory. With the help of an electrode, the seal is cut off from the surface of the skin at the base. The resulting tissue fragment is sent for histology.
- Removal with liquid nitrogen. Cryotherapy is used only in cases where other methods are not available. Low temperature also helps to reduce bleeding, but not as good as electrocoagulation. In this regard, a mixture of lidocaine with epinephrine is recommended for anesthesia. Epinephrine causes a sharp narrowing of blood vessels at the injection site, prolongs the duration of the local anesthetic.
- Laser removal. Laser coagulation is an almost bloodless method, after which, if the procedure is carried out correctly, no noticeable scars remain. Blood cells contain the pigment hemoglobin, which absorbs the energy of laser pulses much more actively than surrounding tissues. This allows the laser beam to affect the papule location area differentially. Vascular formation is removed, and healthy cells remain intact.
Regardless of which surgical method was used, a round-shaped wound covered with a dense dark crust remains at the site of the manipulation. Optimal conditions for epithelization are created under it. The crust cannot be removed until the wound is completely healed, otherwise there is a risk of scar development. This is the only limitation of the postoperative period. The appointment of conservative treatment is advisable only at the first signs of relapse. In this case, an ointment containing 5% imiquimod is applied topically.
Prognosis and prevention
In the case of an established and confirmed diagnosis of pyogenic granuloma, the prognosis for life and recovery is favorable. Regression of compaction without treatment is observed in every second case. Surgery gives a complete cure, but there is always a risk of relapse. A young papule may appear in the same place where the remote node was located. The persistent course requires a more attentive attitude to the causal factors of the appearance of pyogenic granuloma, their elimination as far as possible. Methods for the prevention of botryomycoma due to the lack of accurate data on the etiology of the disease have not been developed; injury to the skin and mucous membranes should be avoided, dermatoses should be treated in a timely manner.