Pyogenic granuloma

Clinical features

• Rapidly growing (days to weeks) red-violaceous papule, polypoid nodule or peduculated mass; often with an epithelial collarette at the base.
• Friable — bleeds with minimal trauma; may ulcerate, crust and discharge serosanguinous fluid.
• Most common on the head and neck, fingers (especially nail fold), lips and oral mucosa (gingival).
• Frequent precipitants: minor trauma, oral contraceptives or pregnancy hormones (epulis gravidarum on gingiva), retinoid or chemotherapy treatment.
• Median age — wide range; common in children, young adults, pregnancy.

Critical differential — DO NOT MISS

• Amelanotic / nodular melanoma — the single most important miss. Any rapidly growing, bleeding red nodule in an adult should be excised and sent for histology.
• Basal cell carcinoma — nodular ulcerated BCC can mimic pyogenic granuloma.
• Cutaneous squamous cell carcinoma — particularly on the lip or scalp.
• Kaposi sarcoma — multifocal, particularly in HIV-positive or transplant recipients.
• Cutaneous metastasis — friable, vascular, in patients with known cancer.
• Angiosarcoma — particularly on irradiated breast or scalp of elderly.
• Bacillary angiomatosis — HIV-positive patients with Bartonella infection.
• Glomus tumour — subungual differential.

Histology

• Polypoid lobular proliferation of small capillary vessels in a loose oedematous stroma — hence the more accurate term "lobular capillary haemangioma".
• Ulcerated surface with overlying neutrophilic inflammation and fibrin.
• Epithelial collarette (acanthotic epidermis enclosing the lesion at its base).
• No cytological atypia, no abnormal mitoses, no infiltrative growth — distinguishing from malignant vascular lesions.
• Negative HHV-8 (excludes Kaposi sarcoma); negative MYC amplification (excludes secondary angiosarcoma).

Management

• Excisional shave or punch biopsy with histological confirmation is preferred — particularly for any solitary lesion in an adult.
• Curettage and electrocautery — acceptable when histology is requested and the entire lesion can be sampled.
• Pulsed dye laser, imiquimod, beta-blocker (timolol) gel — for selected paediatric or recurrent lesions, but should not replace histological confirmation in adult-onset disease.
• Pregnancy-associated lesions often regress post partum — observe if certain of diagnosis.
• Recurrence after curettage — common (10–15%); offer wider excision and full histology.
• Discontinue any precipitating drug (retinoid, EGFR inhibitor) where feasible.

Prognosis

Excellent with complete excision. The clinical importance lies entirely in confirming the benign diagnosis histologically and excluding the malignant mimics listed above. A "missed melanoma masquerading as pyogenic granuloma" is a well-documented harm; the threshold for excision and histological assessment should be very low.