Treating A Patient With A Solitary Vascular Soft Tissue Mass On The Hallux
Current Insights On Etiology, Pathophysiology And Epidemiology
A pyogenic granuloma commonly arises secondary to low-grade local irritation and/or traumatic injury. Hormonal factors play a role as well with pyogenic granuloma often presenting during pregnancy and less commonly with oral contraceptive use. The proliferative effect of estrogens theoretically contributes to the development of these lesions.10 In addition to trauma and hormonal factors, researchers have reported several other triggering factors for the development of pyogenic granuloma, including pulse dye laser, systemic and topical retinoids, antiretrovirals, chemotherapy, erythropoietin and anti-rheumatologic drug therapy.11-22
The specific pathophysiology for the development of pyogenic granuloma is unknown. Despite its name, pyogenic granulomas do not have an infectious etiology. It is poorly understood whether pyogenic granulomas are a reactive process or a tumor. Studies have suggested virus, arteriovenous malformations, abnormal production of angiogenic growth factors and cytogenic abnormalities to play a role in the development of pyogenic granuloma.23-27
Godfraind and colleagues showed a pyogenic granuloma to be more of a reactive process resulting from tissue injury followed by an impaired wound healing response during which vascular growth results from tyrosine-kinase receptors and the nitric oxide pathway.27 Other specific etiologic factors that play a role in the development of pyogenic granuloma include tumorigenesis secondary to over production of transcription factors pATF2 and STAT324, and angiogenesis with endothelial nitric oxide synthases, CD34 and CD105/endoglin expression.23,25
Pyogenic granulomas are common skin lesions accounting for 0.5 percent of all skin nodules in children and occurring in up to 5 percent of pregnancies.9,28 In children, there is a 3:2 male: female ratio.29 However, in adults, pyogenic granulomas are more common in females due to pregnancy lesions.29 Pyogenic granulomas occur most commonly in the second decade of life in adults and around 6 years of age in children.30
A Guide To Making A Differential Diagnosis
Differential diagnoses for pyogenic granuloma include angiokeratoma, bacillary angiomatosis, basal cell carcinoma and nodular melanoma.31
Angiokeratomas are benign cutaneous capillary lesions that present as small red to blue papules with hyperkeratosis. These lesions are typically smaller, slower growing and often multiple in comparison to larger, rapidly growing and solitary pyogenic granulomas.31
Bacillary angiomatosis is a vascular proliferative lesion associated with Bartonella infection. It occurs most commonly in immunocompromised individuals with a history of HIV infection, organ transplant, leukemia or chemotherapy.32 Bacillary angiomatosis has an appearance identical to pyogenic granuloma but tends to occur in greater numbers.
Basal cell carcinoma is a malignant skin neoplasm arising from the basal cell layer of the epidermis. Basal cell carcinoma is the most common form of skin cancer. It typically presents as a pearly papule with telangiectasia and the lesions may become ulcerated.31 Basal cell carcinoma grows at a slow rate in comparison to rapid growth of pyogenic granuloma.
Nodular melanoma presents as a rapidly enlarging red, black or skin colored lump that can have a smooth, rough or ulcerated surface.31 Nodular melanoma is the most aggressive type of melanoma with malignant cells that proliferate downward through the skin. It is the most important tumor to differentiate from pyogenic granuloma.