Treating A Patient With A Solitary Vascular Soft Tissue Mass On The Hallux

Kristine Hoffman, DPM

A 62-year-old female presented with a chief complaint of a soft tissue growth on her left big toe. She reported the lesion to be red, raised and bleeding with pressure. There was a small amount of drainage on the bandage she used to protect the foot in shoe gear.

   The lesion began following a puncture wound with a stick while she was gardening the previous summer. The lesion was present for several months and then fell off when she was wearing closed toed shoes in the winter. The area of the soft tissue mass had nearly healed with the exception of a small area of discolored callus. Gradually, the lesion recurred over the last several months.

   The patient’s past medical history included hypertension, hyperthyroidism, hyperlipidemia, impaired fasting glucose and sinusitis. Her medications included aspirin, vitamin D, estradiol, hydrochlorothiazide, levothyroxine, losartan (Cozaar, Merck) and simvastatin (Zocor, Merck). Her past surgical history included a hysterectomy. She denied tobacco or illicit drug use, and reported rare alcohol use.

   The physical exam revealed a large pedunculated lesion extending off the plantar medial aspect of the left hallux. The lesion measured approximately 0.9 cm in diameter with a 0.3 cm stalk. It was red, bled easily with pressure and had surrounding maceration. I removed the lesion with full thickness surgical excision.

Key Questions To Consider

1. In what patient populations do these lesions occur?
2. What are the potential causes?
3. What are the differential diagnoses?
4. What are the recommended treatment modalities?

Answering The Key Diagnostic Questions

1. Pyogenic granulomas are common in children, adults in their 20s and pregnant females.
2. The most common causes of pyogenic granuloma include trauma and hormonal factors.
3. Differential diagnoses for pyogenic granuloma include angiokeratoma, bacillary angiomatosis, basal cell carcinoma and nodular melanoma.
4. The recommended treatment modalities for pyogenic granuloma are full thickness surgical excision or cauterization with silver nitrate.

What You Should Know About Pyogenic Granuloma

Pathological analysis revealed the presence of a pyogenic granuloma. Pyogenic granulomas are relatively common vascular lesions that arise on the skin and oral mucosa. Researchers have shown these lesions to result from irritation, trauma or hormonal factors.1,2 The lesions typically present as a solitary red, moist papule or nodule that bleeds easily. Pyogenic granulomas tend to present suddenly and grow rapidly over the course of a few weeks.

   Pyogenic granulomas are also known as lobular capillary hemangioma, granulation tissue-type hemangioma, eruptive hemangioma, granuloma gravidarum and pregnancy tumors. Pyogenic granulomas are misnamed as they are neither infectious nor granulomatous. Authors have suggested that the most appropriate name for this neoplasm is lobular capillary hemangioma because the lesions consist of lobular clusters of capillaries in a dense stroma, accompanied by an inflammatory infiltrate.3

   Pyogenic granulomas most commonly present as solitary papules or nodules with a shiny or moist red surface that bleeds easily with pressure. The lesions frequently develop rapidly over the course of a few weeks. The size of the lesions varies from several millimeters to a few centimeters. Some lesions may be pedunculated and quite large. The lesions may exhibit a small amount of drainage leading to maceration and crust formation of the surrounding normal soft tissues. Older lesions frequently develop an ulcerated surface or areas of necrosis. Resolving lesions present as soft, fibrous papules. The lesions occur at various sites including the head, neck, oral mucosa and areas prone to trauma including the digits and plantar foot.

   Authors have reported several variant forms of pyogenic granuloma including disseminated pyogenic granuloma, pyogenic granuloma with satellitosis, intravenous pyogenic granuloma, subcutaneous pyogenic granuloma, eruptive pyogenic granuloma and medication-induced granuloma.4-9

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