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Dermatology Diagnosis

When A Patient Presents With Red Lesions Around Multiple Toenails And Fingernails

A 24-year-old female patient presented to the office with a chief concern of asymptomatic lesions around multiple toenails and fingernails. She reported that the lesions appeared somewhat rapidly over the course of several weeks and that they bleed easily and profusely with the slightest friction or irritation. She denied any history of antecedent trauma to the affected toes or fingers. Her primary care physician originally diagnosed paronychia and prescribed mupirocin ointment followed by a 10-day course of cephalexin, neither of which had any effect. 

Her medical history included well-controlled atopic dermatitis and moderate to severe acne, which was being treated with isotretinoin. The physical exam revealed friable, bright red hemorrhagic papules at multiple lateral nail folds that were more prominent on the fingers than on the toes. Neurovascular status was intact bilaterally. The actual nail plates were unremarkable, and specifically, there was no nail incurvation noted. The lesions did not exhibit any tenderness to palpation, drainage, exudate or odor. However, a few of the lesions did have mild hemorrhagic crusting present. I did not note any associated lichenification or scaling on the hands or feet. The patient also did not have any other cutaneous findings on examination aside from acne on the face and back. 

Due to the findings of the clinical examination and aspects of the patient’s medical history, there was not an immediate need to biopsy the lesion in this particular case. 

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Key Questions To Consider 

1. What are the important diagnostic characteristics of this patient’s lesions? 

2. What is the differential diagnosis? 

3. What histologic characteristics might be important in this diagnosis? 

4. What treatment options exist for these types of lesions? 

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Answering The Key Diagnostic Questions 

1. This patient had shiny, red, round exophytic papules with crusting. Due to their fragile nature, they bleed copiously with even the slightest trauma. 

2. Differential diagnosis of multiple periungual lesions includes pyogenic granuloma, paronychia and traumatized or excoriated verrucae. A broader differential diagnosis includes typical hemangioma, Spitz nevus, digital fibrokeratoma, glomus tumor, amelanotic melanoma, basal cell carcinoma, squamous cell carcinoma, angiosarcoma (in immunosuppressed patients), bacillary angiomatosis and Kaposi’s sarcoma. 

3. Histologic examination of these lesions when indicated may reveal a lobular pattern of vascular proliferation with or without inflammatory infiltrate or edema. There is usually acanthosis or hyperkeratosis at the periphery of the lesion. Overlying the lesion, the epidermis is often thinned or ulcerated. 

4. Treatment of the lesions involves discontinuation of any possible trigger or management of any associated cutaneous disease. If no underlying triggers or conditions are identified, there are multiple therapeutic options for removal of individual lesions. 

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Current Insights On Pyogenic Granulomas 

We diagnosed this patient with pyogenic granulomas, also known as lobular capillary hemangiomas. These growths are benign acquired lesions that can occur in all age groups with both genders affected equally.1,2 The term “pyogenic” is a misnomer as the lesions were previously and mistakenly thought to represent an exaggerated granulomatous reaction to an infectious insult.1,2 Despite this, there is ongoing debate about a possible infectious (Staphyloccus, Streptococcus, human herpes virus-8 (HHV8)) etiology in at least a minority of cases.1,2 The suspicion is that an imbalance of pro- and anti-angiogenic factors trigger a rapid proliferation of blood vessels.1,2 

The most common presentation is a solitary lesion at a site of trauma in younger individuals. In adults, cutaneous pyogenic granulomas appear more commonly on the trunk and extremities in contrast to children whose lesions have a predilection for the head and neck.3,4 

Another variant is presentation in the oral mucosa (lips or gingiva) in pregnant women. In these cases, the lesions are known as epulis gravidarum or pregnancy epulis. In rare circumstances, lesions may occur in the gastrointestinal tract and one generally only discovers this as a result of overt or chronic bleeding causing anemia.3,4 

A number of medications can trigger the formation of pyogenic granulomas. These include retinoids (isotretinoin, acitretin), antiretrovirals (indinavir), antineoplastics (pyrimidine analogs, taxanes, epidermal growth factor inhibitors, tyrosine kinase inhibitors, v-raf murine sarcoma viral oncogene homolog B1 (BRAF) inhibitors), immunosuppressive agents (cyclosporine, tacrolimus, etanercept) and, rarely, oral contraceptives.5,6,7,8 Pyogenic granulomas may arise in areas of laser treatment for preexisting vascular malformations such as port-wine stains or arteriovenous malformations.9 

Periungual lesions can be caused by mechanical trauma such as pedicures, penetration of foreign bodies, repetitive nail biting or picking, and chronic friction that may occur with prolonged walking or ill-fitting shoes. Peripheral nerve injury and cast immobilization are other predisposing factors. Less commonly, one may see periungual pyogenic granulomas in patients with psoriasis, atopic dermatitis, spondyloarthritis, sarcoidosis, pemphigus vulgaris or as a consequence of chronic paronychia.10 

Pertinent Treatment Considerations For Pyogenic Granulomas 

One can best achieve management of these lesions by identifying the underlying cause. In this patient’s case, discontinuing isotretinoin allowed the lesions to spontaneously resolve over the course of several weeks. In patients on antineoplastic agents, where stopping the medication is not possible, one can manage the lesions with weekly chemical cautery or electrodessication.11 For pregnant women, it is common for mucosal pyogenic granulomas to spontaneously involute after delivery. If one suspects a foreign body as the cause of a pyogenic granuloma, plain radiographs may prove useful. Adequate management of any associated cutaneous conditions is imperative. 

Treatment of most simple pyogenic granulomas involves shave excision and electrodessication. If possible, clinicians should pursue histopathologic evaluation of lesions to rule out the number of malignant diagnoses that can mimic pyogenic granulomas. 

Other treatment options include laser therapy (Nd:YAG, pulsed dye, carbon dioxide, diode lasers), cryosurgery, injectable sclerosing agents, topical imiquimod or systemic or topical treatment with the beta-andrenergic receptor antagonists timolol or propranolol. Treatment with beta-adrenergic receptor antagonists, whether topical or oral, requires monitoring for bradycardia, hypotension, hypoglycemia and bronchoconstriction.12,13,14 

Final Thoughts 

There is no currently accepted standard of care for pyogenic granulomas as clinical trials comparing efficacy of treatment modalities are limited. Regardless of chosen treatment, patients understand that local recurrence is exceedingly common and may occur as a solitary lesion or rarely as satellitosis with multiple clustered papules.15 

If pyogenic granulomas are not associated with medications or pregnancy, they typically do not regress without treatment. Although malignant transformation has not been reported, there are complications that can occur if pyogenic granulomas are untreated. These complications may include ulceration, repeated hemorrhage, secondary infections and cosmetic disfigurement.1 

Dr. Hanft is a Fellow of the American Academy of Dermatology and is in private practice in Austin, Tx. 

Dermatology Diagnosis
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By Valerie Hanft, MD, FAAD
References

1. James WD, Berger TJ, Elston DM. Andrews Diseases of the Skin (10th ed.). Philadelphia: WB Saunders; 2006: 592. 

2. Adams DO. The granulomatous inflammatory response. A review. Am J Pathol. 1976;84(1):164-192. 

3. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma); a clinicopathologic study of 178 cases. Pediatr Dermatol. 1991;8(4):267-276. 

4. Wollina U, Langner D, Franca K, Gianfaldoni S, Lotti T, Tchernev G. Pyogenic granuloma-a common benign vascular tumor with variable clinical presentation: new findings and treatment options. Open Access Maced J Med Sci. 2017;5(4):423-426. 

5. Simmons BJ, Chen L, Hu S. Pyogenic granuloma association with isotretinoin treatment for acne. Australas J Dermatol. 2016;57(4):e144-145. 

6. Exner JH, Dahod S, Pochi PE. Pyogenic granuloma-like acne lesions during isotretinoin therapy. Arch Dermatol.1983;119(10):808-811 

7. Benedetto C, Crasto D, Ettefagh L, Nami N. Development of periungual pyogenic granuloma with associated paronychia following isotretinoin therapy: a case report and a review of the literature. J Clin Aesthet Dermatol. 2019;12(4):32-36. 

8. Piguet V, Borradori L. Pyogenic granuloma-like lesions during capecitabine therapy. Br J Derma tol. 2002;147(6):1270. 

9. Beers BB, Rustad OJ, Vance JC. Pyogenic grandma following laser treatment of a port-wine stain. Cutis. 1988;41(4)266-268. 

10. Zaiac MN, Walker A. Nail abnormalities associated with systemic pathologies. Clin Dermatol. 2013;31(5):627-649. 

11. Lacouture ME, Anadkat MJ, Bensadoun RJ, et al. Clinical practice guidelines for the prevention and treatment of EGFR inhibitor-associated dermatology toxicities. Support Care Cancer. 2011;19(8)1079-1095. 

12. Koo MG, Lee SH, Han SE. Pyogenic granuloma: a retrospective analysis of cases treated over 10 years. Arch Craniofac Surg. 2017;18(1):16-20. 

13. Giblin AV, Clover AJ, Athanassopoulos A, Budny PG. Pyogenic granuloma—the quest for optimum treatment:an audit of treatment of 408 cases. J Last Reconstr Aesthet Surg. 2007;60(9):1030-1035. 

14. Piraccini BM, Alessandrini A, Dika E, Starace M, Patrizi A, Neri I. Topical propanolol 1% cream for pyogenic granulomas of the nail:open-label study in 10 patients. J Eur Acad Dermatol Venereol. 2016;30(5):901-902. 

15. Bacher J. Assaad D. Adam DN. Pyogenic granuloma of the foot with satellitosis: a role for conservative management. J Cutan Med Surg. 2011;15(1):58-60. 

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