What Causes Pyogenic Granulomas?

Pyogenic granulomas are small, benign skin lesions that often occur during pregnancy.

Pyogenic granulomas (also called lobular capillary hemangiomas) are common, benign, rapidly-growing, brittle vascular lesions of the skin and mucosa. They frequently occur in children and young adults, and grow rapidly over a few weeks, often on the head, neck, upper trunk, and extremities. 

Pyogenic granuloma is common as well in pregnancy (and in rare cases, with oral contraceptive usage), usually appearing on the gums or elsewhere in the mouth, and may be called a "pregnancy tumor."

Symptoms of pyogenic granuloma include:

• A solitary growth that grows rapidly over a few weeks
• Size ranges from a few millimeters to several centimeters 
  • The average size is 6.5 mm, or just over 2-1/2 inches
• Painless, glistening, raspberry-red lesions that can bleed spontaneously or when irritated
• Lesions may be:
  • Moist
  • Bleeding
  • Ulcerated
  • Filled with pus
  • Crusty
• The head, neck, extremities, fingers and toes, and upper trunk are most commonly affected, but lesions can also affect the genitals, eyelids, and mouth
  • Oral lesions are most common on the lips, tongue, and gums
• May appear during pregnancy, especially on the gums or in the mouth

Lesions are benign (noncancerous).

The cause of the pyogenic granulomas (lobular capillary hemangiomas) is unknown. Some suspected causes include:

• Trauma
• Hormones
• Viruses
• Underlying microscopic arteriovenous malformations (abnormal connections between arteries and veins)
• Production of angiogenic factors
• Cytogenetic clonal deletion abnormalities (a localized gene mutation) 
• Use of certain medications, such as:
  • Systemic and topical retinoids
  • Antiretrovirals
  • Anti-cancer drugs
    • Epidermal growth factor receptor inhibitor therapy 
    • 5-fluorouracil
    • Capecitabine
    • Mitoxantrone (an anthracenedione)
    • Docetaxel and paclitaxel
    • mTOR inhibitors
    • Vemurafenib
    • Blinatumomab
    • Ramucirumab
  • Other drugs
    • Cyclosporine
    • Erythropoietin
    • Levothyroxine
    • Anti-CD 20 monoclonal antibody therapy
    • Anti–tumor necrosis factor-alpha therapy
    • Oral contraceptives

Pyogenic granulomas can often be diagnosed with a physical examination. In some cases, more extended testing may need to be done such as:

• Dermoscopy: examination of the skin using a special microscope
• Biopsy: a tissue sample is taken and examined under a microscope
• Cultures of any fluid or pus in the lesion

Some smaller pyogenic granulomas (lobular capillary hemangiomas) may not require treatment and will go away on their own. It is important not to pick at the pyogenic granulomas or try to remove them on your own, as they can bleed extensively. They need to be removed properly by a medical professional. Usually a dermatologist will treat these lesions.

When treatment for pyogenic granulomas is needed, it may involve:

• Surgical removal of the pyogenic granuloma
  • Full-thickness excision, shave excision, or curettage
  • Cryotherapy
  • Laser therapy
• Topical and intralesional therapies 
  • Sclerotherapy with injection of ethanolamine oleate, sodium tetradecyl sulfate, or polidocanol 
  • Chemical cauterization with silver nitrate 
  • Topical phenol 
  • Topical imiquimod cream, alitretinoin gel, and ingenol mebutate
  • Topical beta blockers, including topical propranolol and timolol
  • Suture ligation (closing off) of the lesion base using absorbable suture material.
    • Following ligation, the tumor tissue dies (becomes necrotic) and falls off in days to weeks.
  • Intralesional injection of bleomycin, corticosteroids, or absolute ethanol

Pyogenic granulomas are benign (noncancerous), and complications are uncommon. 

Complications may include: 

• Significant discomfort and bleeding 
• Bleeding may rarely be severe enough to cause anemia
• Localized infections
• Recurring lesions