The abnormal dermis in pyogenic granuloma. Histochemical and ultrastructural observations

Effectiveness and safety of 0.5% timolol solution in the treatment of pyogenic granuloma: A randomized, double-blind and placebo-controlled study

Introduction Pyogenic granulomas are benign vascular lesions of the skin and mucosa which are often a source of concern because of their recurrent bleeding even with minimal trauma. Current treatment for pyogenic granuloma is ablative; no medical therapy is standardized to date. Timolol, due to its vasoconstrictive effect, vascular growth factor inhibition and apoptosis promotion properties, is a potential therapeutic option. Objectives: To assess the effectiveness and safety of topical timolol in the treatment of pyogenic granulomas. Methods A two-centre, double-blind and placebo-controlled trial (Registration CTRI/2019/04/018581) was conducted. Patients of either sex were recruited with pyogenic granuloma lesions of less than eight weeks duration. Topical treatment with 0.5% timolol or matching glycerin placebo was continued for six weeks. Changes in color, size, bleeding tendency, physicians' and patients' global assessments and adverse events were assessed. Results Forty subjects were randomized between the two groups which were comparable in age, sex, duration of illness and baseline lesion size.Significant improvement was noted with timolol, with color change from first follow-up onwards and lesion size reduction from second follow-up onward. Patients' assessment of bleeding tendency also showed imrovement from the second visit onward. Between-group comparison showed significant difference with respect to percentage reduction in size (timolol 40.9%, placebo 3.4%; P = 0.002). Rescue treatment (electrosurgery) was required in five patients on placebo and in one in the timolol group (P = 0.182). Complete resolution occurred in 2 (10%) patients with timolol and in no patients on placebo (P = 0.231). Limitations: We observed effects of treatment for only six weeks. Conclusion Topical timolol may be a treatment option for early pyogenic granulomas but complete resolution is unlikely in six weeks. Studies of longer duration are required to assess resolution and recurrence rates.

Management of Pyogenic Granulomas Following Burn Wounds

Pyogenic granuloma following burns (PGB) manifest in patients with different clinical and pathological features which is completely different with classic pyogenic granuloma. Up to now, there is no conclusive theory about presents of PG and its accurate etiology. This is a short brief about a 49-yr-old female with, TBSA 1% which PG develop on her burned area after 2 weeks.

Heterogeneous conceptualization of etiopathogenesis: Oral pyogenic granuloma

Oral pyogenic granuloma or granuloma pyogenicum is a conspicuous lesion. The word pyogenic granuloma is a misterm since the situation is not related with pus and histologically does not exemplify a granuloma. An oral pyogenic granuloma is obvious to involve the gingiva generally. Extragingivally, it can present on the buccal mucosa, lips, tongue, and palate. A report of trauma is prevalent in such sites. The pathogenesis of the lesion is still unclear, although it was initially supposed to be a botryomycosis infection. It is suggested that etiology of pyogenic granuloma was the reaction of tissues to minor injury or chronic irritation, thus open a pathway for the entrance of nonspecific microorganisms, although microorganisms are not often expressed within the lesion. Hence, this review recapitulates all diverse concepts of pathogenesis associated with this most often and most mysterious lesion of the oral cavity.

Pyogenic granuloma in a 5-month-old treated with topical timolol

A 5-month-old healthy female presented with a pyogenic granuloma on the cheek. The lesion was treated with topical 0.5% gel-forming solution, resulting in regression of the lesion after 1 month of treatment and no recurrence at 8 months. This case suggests that treatment of pyogenic granulomas with topical timolol may be considered, especially when other treatment modalities are challenging or could result in significant scarring.

Pyogenic granuloma of the gingiva: A misnomer? - A case report and review of literature

Pyogenic granuloma is a commonly occurring inflammatory hyperplasia of the skin and oral mucosa. It is not associated with pus as its name suggests and histologically it resembles an angiomatous lesion rather than a granulomatous lesion. It is known by a variety of names such as Crocker and Hartzell's disease, granuloma pyogenicum, granuloma pediculatum benignum, benign vascular tumor and during pregnancy as granuloma gravidarum. This tumor like growth is considered to be non-neoplastic in nature and it presents itself in the oral cavity in various clinical and histological forms. Due to its frequent occurrence in the oral cavity, especially the gingiva, this article presents a case report of a large pyogenic granuloma of the gingiva and its management, reviews the literature and discusses why the term "pyogenic granuloma" is a misnomer.

Oral pyogenic granuloma: Various concepts of etiopathogenesis

Pyogenic granuloma or granuloma pyogenicum is a well-known oral lesion. The name pyogenic granuloma is a misnomer since the condition is not associated with pus and does not represent a granuloma histologically. Pyogenic granuloma of the oral cavity is known to involve the gingiva commonly. Extragingivally, it can occur on the lips, tongue, buccal mucosa, palate, and the like. A history of trauma is common in such sites. The etiology of the lesion is not known, though it was originally believed to be a botryomycotic infection. It is theorized that pyogenic granuloma possibly originates as a response of tissues to minor trauma and/or chronic irritation, thus opening a pathway for invasion of nonspecific microorganisms, although microorganisms are seldom demonstrated within the lesion. Pathogenesis of pyogenic granuloma is still debatable. Medline and PubMed databases were searched under the following key terms: Pathogenesis of oral pyogenic granuloma, pyogenic granuloma, and oral pyogenic granuloma. This search was limited to articles on human/animal studies which were published in English language. After reviewing the searched articles, the relevant articles were selected for the present review. Through this article, we have tried to summarize and present all the concepts of pathogenesis related to this most common and most mysterious oral lesion.

Laser: a powerful tool for treatment of pyogenic granuloma

Lasers have opened a new door for the treatment of various disorders. Treatment of soft tissue intraoral mucosal growth by laser has profound effect on the patient acceptability taking the functional and aesthetic factor into consideration. The patient is able to get the outdoor treatment without the phobia of local anaesthetic and is out of the clinic in few minutes in contrast to the traditional method of surgical excision. Very few cases have been reported in literature regarding treatment of mucosal growth by soft tissue lasers. We present a case of recurrent pyogenic granuloma in a patient treated with an alternative approach, that is, diode laser, without the use of anaesthesia, sutures, anti-inflammatory drugs, or analgesics. The diagnosis of this lesion is equally important for correct treatment planning.

Oral pyogenic granuloma: a review

Pyogenic granuloma is one of the inflammatory hyperplasias seen in the oral cavity. This term is a misnomer because the lesion is unrelated to infection and in reality arises in response to various stimuli such as low-grade local irritation, traumatic injury or hormonal factors. It predominantly occurs in the second decade of life in young females, possibly because of the vascular effects of female hormones. Clinically, oral pyogenic granuloma is a smooth or lobulated exophytic lesion manifesting as small, red erythematous papules on a pedunculated or sometimes sessile base, which is usually hemorrhagic. The surface ranges from pink to red to purple, depending on the age of the lesion. Although excisional surgery is the treatment of choice for it, some other treatment protocols such as the use of Nd:YAG laser, flash lamp pulsed dye laser, cryosurgery, intralesional injection of ethanol or corticosteroid and sodium tetradecyl sulfate sclerotherapy have been proposed. Because of the high frequency of pyogenic granuloma in the oral cavity, especially during pregnancy, and necessity for proper diagnosis and treatment, a complete review of published information and investigations about this lesion, in addition to knowledge about new approaches for its treatment is presented.

Expression of the endothelial receptor tyrosine kinase Tie2 in lobular capillary hemangioma of the oral mucosa: an immunohistochemical study

BACKGROUND

Lobular capillary hemangioma (LCH) usually occurs in the skin or mucous membranes as a rapidly growing red nodule. LCH is one of the most common vascular lesions in the oral mucosa. Tie2 is a novel, human endothelial receptor tyrosine kinase which may play an important role in blood vessel formation. In this study, we investigated its immunohistochemical expression in LCH of the oral mucosa.

METHODS

Double immunostaining with anti-CD34 and antialpha smooth muscle actin (SMA) antibodies was performed to characterize the cellular expression of Tie2 in 15 cases of this condition.

RESULTS

We found Tie2 immunoreactivity in the ovoid cells only, which were frequently intermingled with alphaSMA-positive cells, especially in the hypercellular portion of LCH.

CONCLUSIONS

These results suggest that the expression of Tie2 in ovoid cells and the interaction between ovoid cells and alphaSMA-positive cells play an important part in the development and progression of LCH.

Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms

This second part of our review about vascular proliferations summarizes the clinicopathologic features of the cutaneous vascular hyperplasias and benign neoplasms. Hyperplasias comprise a heterogeneous group of vascular proliferations that eventually show a tendency to regression. Angiolymphoid hyperplasia with eosinophilia is included within the group of hyperplasias because of its historical denomination and its reactive nature, probably as a consequence of an arteriovenous shunt, although usually the lesions do not regress. Pyogenic granuloma, bacillary angiomatosis, intravascular papillary endothelial hyperplasia, and pseudo-Kaposi's sarcoma qualify as vascular hyperplasias because they regress when the stimulus that initiated them is removed. Benign neoplasms form a large group of hemangiomas with distinctive clinicopathologic characteristics, although some of them are of recent description and may produce diagnostic difficulties. We classified cutaneous benign vascular neoplasms according to their cell lineage of differentiation, for example, endothelial, glomus cell, and pericytic differentiation. Subsequent categories are established according to the size of the involved vessels (capillaries, venules and arterioles, or veins and arteries) or the nature of the proliferating vessels (blood or lymphatic vessels). Capillary and cavernous hemangiomas have been the terms classically used to name the most common variants of benign vascular neoplasms (i.e., infantile hemangiomas), but they are not the most appropriate denominations for these lesions. First, these names are not contrasting terms. Furthermore, most of the socalled "cavernous" hemangiomas are not hemangiomas (neoplasms) at all, but venous malformations. The most important conceptual issue is that, at any point in time, a particular hemangioma has its own histopathologic pattern throughout the depth of the lesion. For these reasons, we classified hemangiomas into superficial and deep categories. Some of the lesions reviewed have been recently described in the literature, and they may histopathologically mimic lesions of Kaposi's sarcoma; these include targetoid hemosiderotic hemangioma, microvenular hemangioma, tufted hemangioma, glomeruloid hemangioma, kaposiform hemangioendothelioma, spindle-cell hemangioendothelioma, and benign lymphangioendothelioma. In each of these lesions, we update and emphasize those clinical and histopathologic features that are helpful for differential diagnosis with lesions of authentic Kaposi's sarcoma in any of its three stages of development (patch, plaque, or nodule).

Lobular capillary haemangioma (pyogenic granuloma) of the nose

OBJECTIVE

To present a number of cases with lobular capillary haemangioma (pyogenic granuloma) of the nose; and to discuss the clinical and histopathological diagnosis of this disorder.

METHODS

A clinicopathological study of patients diagnosed with nasal lobular capillary haemangioma who were treated at King Abdel Aziz University Hospital, Riyadh from 1986 to 1995.

RESULTS

The study group consisted of 12 patients (four males and eight females ranging in age from 17 to 65 years; mean 30.1 years). Clinically, most patients presented with epistaxis and a rapidly growing unilateral haemorrhagic mass. Most lesions were located on the septal mucosa. The clinical impression was misleading in some cases. The histological diagnosis was based on the lobular arrangement of capillaries. One case was initially misdiagnosed as angiofibroma. Excisional biopsy was the mainstay of treatment. One instance of recurrence was recorded.

CONCLUSION

This uncommon lesion should be considered in the differential diagnosis of a rapidly growing haemorrhagic lesion within the nasal fossa. Clinical and histological diagnostic pitfalls occur frequently.

Treatment of pyogenic granulomas with the 585 nm pulsed dye laser

BACKGROUND

Current therapeutic alternatives for pyogenic granulomas include surgical excision, electrodesiccation and curettage, cryotherapy, and ablation with CO2 or continuous-wave vascular lasers.

OBJECTIVE

Our purpose was to investigate the use of the 585 nm flashlamp-pumped pulsed dye laser (585 nm PDL) for the treatment of pyogenic granulomas in terms of efficacy, advantages in technique, and side effects.

METHODS

Eighteen patients with symptomatic pyogenic granulomas in a variety of locations were treated with the 585 nm PDL and examined.

RESULTS

Sixteen of 18 treated patients demonstrated both symptomatic and clinical clearing of the lesions with excellent cosmetic results after treatment. The two patients who dropped out after one to two 585 nm PDL treatments were eventually treated successfully with electrodesiccation and curettage. No postoperative complications and no persistent pigmentary changes or scarring were observed. The procedure required no anesthesia, and postoperative care was limited to the application of a topical antibiotic ointment.

CONCLUSION

Our experience suggests that treatment of pyogenic granulomas with the 585 nm PDL is a safe, effective, and reasonable alternative to conventional therapy.

Multiple cutaneous capillary haemangioma in a red partridge (Alectoris rufa)

A 6-year-old healthy decoy red partridge (Alectoris rufa) developed rapidly growing multiple cutaneous nodules in the dorsal aspect of the neck. Histologically, they were distinctly exophytic growths composed of variably-sized blood vessels often surrounded by solid masses of endothelial-like cells set in an oedematous stroma with abundant inflammatory cells. They were diagnosed as multiple cutaneous capillary haemangiomas. These tumours have been described in chickens in association with viral infections and in old budgerigars, but not in partridges.

Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases

Pyogenic granuloma (lobular capillary hemangioma) is a common acquired vascular lesion of the skin and mucous membranes in the pediatric age group. This is a retrospective analysis of 178 patients, 17 years of age and younger (mean age 6.7 yrs). Forty-two percent of the lesions occurred in the first five years of life; only 12% appeared in infants less than 1 year old. The male:female ratio was 3:2. Most patients (74.2%) had no history of trauma or predisposing dermatologic condition. The mean lesional size was 6.5 mm and the mean duration at diagnosis was 3.8 months. The granulomas were most commonly located in the head and neck area (62.4%), followed in order of decreasing frequency by trunk (19.7%), upper extremity (12.9%), and lower extremity (5.0%). The preponderance (88.2%) occurred on the skin, the remaining ones involved the mucous membranes of the oral cavity and conjunctivae. Histologic examination demonstrated normal numbers of mast cells, in contrast to increased mast cells characteristic of proliferative phase hemangiomas. Most lesions (n = 149) were treated by full-thickness skin excision and linear closure; there were no recurrences in this group. The recurrence rate in 23 lesions treated by shave (intradermal) excision and cautery or cautery alone was 43.5%.

Immunocytochemistry of eruptive haemangiomas (pyogenic granulomas)

Eight eruptive haemangiomas (pyogenic granulomas) were stained immunocytochemically. Many of the cells reacted with markers for endothelial cells. The reactions with anti-vWF antibody were weaker than those with UEA-I-lectin and with the monoclonal antibody BMA 120. These results probably reflect reduced capability for storage of vWF by proliferating endothelial cells. Many cells were negative for endothelial-cell markers, and they reacted with a monoclonal antibody against muscle actin. These cells may be myofibroblasts and pericytes. The studies indicate that eruptive haemangiomas are composed of pericytes, myofibroblasts and endothelial cells.

Pyogenic granuloma: evaluation of oral conditions

A consecutive series of 43 pyogenic granulomata in the oral cavity is presented. Most were located to the marginal vestibular gingivae and only a minority (12%) of these had a history of trauma whereas 70% in extragingival locations had a previous history of injury. On the basis of an evaluation of oral conditions the aetiology and the pathogenesis of the pyogenic granuloma are discussed. Trauma, microtrauma due to toothbrushing and gingival inflammation seem to be pathogenetic elements. It is suggested that the granuloma is a localised tissue response to a non-specific irritant.

Multiple angiomatous proliferations of ileal stoma following Campylobacter enteritis. Effect of laser photocoagulation

Multiple polypoid sessile tumors arose at the tip of the ileal stoma of a 37-year-old man, who previously underwent proctocolectomy for ulcerative colitis. The lesions developed shortly after a well-established gastrointestinal infection with Campylobacter jejuni with mucosal ulceration. The histological and ultrastructural examination showed angiomatous proliferations, reminiscent of pyogenic granuloma. The destruction of the tumors by laser photocoagulation was followed by superficial ulcerations of the mucosa, which healed without scarring. Small recurrences, however, could not be prevented.

Pseudosarcomatous angioplasia: atypical presentation of pyogenic granuloma

An unusual case of pyogenic granuloma is presented. Clinical and histological features of this lesion are reviewed. Differential diagnosis, common variants, and treatment modalities are also discussed.