When Should You Biopsy Lesions That Appear To Be Pyogenic Granuloma?

William Fishco DPM FACFAS

Pyogenic granuloma is a common condition that we see almost every day in clinical practice. This vascular tumor is a benign growth of skin and mucus membranes that can present as a nodule or polyp that bleeds easily after trauma. More often than not, these vascular growths appear on the nail folds and are associated with a paronychia.

Unfortunately, there are some nasty conditions that masquerade as pyogenic granuloma, some of which are malignant. These conditions include amelanotic melanoma, basal cell carcinoma, squamous cell carcinoma, metastatic carcinoma and Kaposi’s sarcoma.

Luckily, the carcinomas that look like pyogenic granuloma are rare. After years of taking biopsies, I have seen a few carcinomas. More often, I detect a variety of hemangiomas.

Certainly, the amelanotic melanoma is the most critical condition that we need to rule out. Typically, amelanotic melanoma will bleed less than pyogenic granuloma. Also, unlike pyogenic granuloma, there is never a history of trauma associated with melanoma.

Here are some general rules for when to biopsy the lesion:

1. Biopsy when you see what looks like a pyogenic granuloma in an unusual location (i.e. not associated with a paronychia).
2. Biopsy when there is a recurring growth or proliferation of granuloma after the initial removal.
3. Biopsy when the patient reports that the granuloma has been present for more than six months.
4. Biopsy when your patient has a history of metastatic carcinoma.
5. Biopsy when the granuloma just looks different than “typical” pyogenic granulomas.

It is simple to biopsy a vascular granuloma. After anesthetizing the area, simply perform curettage and place the tissue into a jar of formalin. After the curettage, cauterize the base with an electrocautery unit. I avoid using silver nitrate because it makes a mess of the tissues. If you have these patients come back in a week or so, the tissues are gray, wet and soupy. Alternately, after you use a hyfrecator, the tissue is dry and healed.

In general, remember, you will never kick yourself for taking a biopsy but I can’t say the same for the contrary.

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