Dermatologic Manifestations of Pyogenic Granuloma (Lobular Capillary Hemangioma) Author: Joseph C Pierson, MD; Chief Editor: Dirk M Elston, MD  

Updated: Apr 29, 2010 

Background

Pyogenic granuloma (lobular capillary hemangioma) is a relatively common benign vascular lesion of the skin and mucosa whose exact cause is unknown. Pyogenic granulomas are misnamed; they are neither infectious nor granulomatous. The lesion usually occurs in children and young adults as a solitary glistening red papule or nodule that is prone to bleeding and ulceration. Pyogenic granulomas typically evolve rapidly over a period of a few weeks, most often on the head, neck, extremities, and upper trunk.

Pyogenic granuloma often arises in pregnancy (or rarely with oral contraceptive usage), particularly on the gingiva or elsewhere in the oral mucosa, and then is termed the "pregnancy tumor." Other pyogenic granuloma variants that have been well documented include the disseminated, subcutaneous, intravenous, and systemic medication (retinoid, protease inhibitor, and chemotherapy)–induced subtypes. Also see the eMedicine article Oral Pyogenic Granuloma.

Removal of pyogenic granuloma is indicated to alleviate any bleeding, discomfort, cosmetic distress, and diagnostic uncertainty. A number of malignant tumors may clinically mimic pyogenic granuloma, making histopathologic confirmation important if the presentation is atypical. Aside from cutaneous and oral lesions, pyogenic granuloma has been reported throughout the gastrointestinal tract, the nasal mucosa, the larynx, and the conjunctiva and cornea. This article discusses only cutaneous and oral involvement.

Pathophysiology

The precise mechanism for the development of pyogenic granuloma (lobular capillary hemangioma) is unknown. Trauma, hormonal influences, viral oncogenes, underlying microscopic arteriovenous malformations, the production of angiogenic growth factors, and cytogenetic abnormalities have all been postulated to play a role. The overexpression of transcription factors P-ATF2 and STAT3 also may play a role in tumorigenesis.[1]

Epidemiology

Frequency

United States

Pyogenic granuloma is relatively common, representing 0.5% of all skin nodules in children. The pregnancy tumor variant of pyogenic granuloma occurs in up to 5% of pregnancies.

International

International frequency for pyogenic granuloma is likely similar to that of the United States.

Mortality/Morbidity

Pyogenic granuloma is a benign lesion; however, discomfort and bleeding occasionally may be significant. The latter may rarely be severe enough to cause anemia.[2] Lesions that recur despite repeated excisions can be particularly problematic.

Race

The frequency of pyogenic granuloma appears to be similar in all races.

Sex

Females are affected more commonly by pyogenic granuloma than males, due to the pregnancy tumor phenomenon.

Age

Pyogenic granuloma is rare in children younger than 6 months. The mean age of presentation is 6.7 years. Otherwise, aside from those lesions occurring in pregnancy, the frequency declines linearly with age. Also see the eMedicine Pediatrics article, Pyogenic Granuloma.

References

1. Chen SY, Takeuchi S, Urabe K, et al. Overexpression of phosphorylated-ATF2 and STAT3 in cutaneous angiosarcoma and pyogenic granuloma. J Cutan Pathol. Aug 2008;35(8):722-30. [Medline].

2. Alexander AM Jr, Koh JK. Granuloma pyogenicum (pyogenic granuloma) causing severe anemia. Arch Dermatol. Jul 1972;106(1):128. [Medline].

3. Cheah S, DeKoven J. Pyogenic granuloma complicating pulsed-dye laser therapy for cherry angioma. Australas J Dermatol. May 2009;50(2):141-3. [Medline].

4. Teknetzis A, Ioannides D, Vakali G, Lefaki I, Minas A. Pyogenic granulomas following topical application of tretinoin. J Eur Acad Dermatol Venereol. May 2004;18(3):337-9. [Medline].

5. Bouscarat F, Bouchard C, Bouhour D. Paronychia and pyogenic granuloma of the great toes in patients treated with indinavir. N Engl J Med. Jun 11 1998;338(24):1776-7. [Medline].

6. Suarez-Amor O, Cabanillas M, Monteagudo B, de Las Heras C, Cacharron JM. [Disseminated pyogenic granuloma induced by erythropoietin?]. Actas Dermosifiliogr. Jun 2009;100(5):439-40. [Medline].

7. Vergara A, Isarria MJ, Rodriguez-Peralto JL, Guerra A. [Disseminated lobular capillary hemangiomas]. Actas Dermosifiliogr. Jul-Aug 2008;99(6):494-6. [Medline].

8. Curr N, Saunders H, Murugasu A, Cooray P, Schwarz M, Gin D. Multiple periungual pyogenic granulomas following systemic 5-fluorouracil. Australas J Dermatol. May 2006;47(2):130-3. [Medline].

9. Piguet V, Borradori L. Pyogenic granuloma-like lesions during capecitabine therapy. Br J Dermatol. Dec 2002;147(6):1270-2. [Medline].

10. Freiman A, Bouganim N, O'Brien EA. Case reports: mitozantrone-induced onycholysis associated with subungual abscesses, paronychia, and pyogenic granuloma. J Drugs Dermatol. Jul-Aug 2005;4(4):490-2. [Medline].

11. Devillers C, Vanhooteghem O, Henrijean A, Ramaut M, de la Brassinne M. Subungueal pyogenic granuloma secondary to docetaxel therapy. Clin Exp Dermatol. Mar 2009;34(2):251-2. [Medline].

12. Segaert S, Van Cutsem E. Clinical signs, pathophysiology and management of skin toxicity during therapy with epidermal growth factor receptor inhibitors. Ann Oncol. Sep 2005;16(9):1425-33. [Medline].

13. Browning JC, Eldin KW, Kozakewich HP, Mulliken JB, Bree AF. Congenital disseminated pyogenic granuloma. Pediatr Dermatol. May-Jun 2009;26(3):323-7. [Medline].

14. Palmero ML, Pope E. Eruptive pyogenic granulomas developing after drug hypersensitivity reaction. J Am Acad Dermatol. May 2009;60(5):855-7. [Medline].

15. Nthumba PM. Giant pyogenic granuloma of the thigh: a case report. J Med Case Reports. Mar 31 2008;2:95. [Medline].

16. Truss L, Dobin SM, Donner LR. Deletion (21)(q21.2q22.12) as a sole clonal cytogenetic abnormality in a lobular capillary hemangioma of the nasal cavity. Cancer Genet Cytogenet. Oct 1 2006;170(1):69-70. [Medline].

17. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol. Dec 1991;8(4):267-76. [Medline].

18. Levy I, Rolain JM, Lepidi H, et al. Is pyogenic granuloma associated with Bartonella infection?. J Am Acad Dermatol. Dec 2005;53(6):1065-6. [Medline].

19. Campbell JP, Grekin RC, Ellis CN, Matsuda-John SS, Swanson NA, Voorhees JJ. Retinoid therapy is associated with excess granulation tissue responses. J Am Acad Dermatol. Nov 1983;9(5):708-13. [Medline].

20. Jose RM, Bennett A, Holmes J. Spitz naevi presenting as pyogenic granulomata. Br J Plast Surg. Oct 2005;58(7):1037-9. [Medline].

21. Zaballos P, Llambrich A, Cuéllar F, Puig S, Malvehy J. Dermoscopic findings in pyogenic granuloma. Br J Dermatol. Jun 2006;154(6):1108-11. [Medline].

22. Zaballos P, Rodero J, Serrano P, Cuellar F, Guionnet N, Vives JM. Pyogenic granuloma clinically and dermoscopically mimicking pigmented melanoma. Dermatol Online J. Oct 15 2009;15(10):10. [Medline].

23. Vega Harring SM, Niyaz M, Okada S, Kudo M. Extramedullary hematopoiesis in a pyogenic granuloma: a case report and review. J Cutan Pathol. Sep 2004;31(8):555-7. [Medline].

24. North PE, Waner M, Mizeracki A, Mihm MC Jr. GLUT1: a newly discovered immunohistochemical marker for juvenile hemangiomas. Hum Pathol. Jan 2000;31(1):11-22. [Medline].

25. Fallah H, Fischer G, Zagarella S. Pyogenic granuloma in children: treatment with topical imiquimod. Australas J Dermatol. Nov 2007;48(4):217-20. [Medline].

26. Georgiou S, Monastirli A, Pasmatzi E, Tsambaos D. Pyogenic granuloma: complete remission under occlusive imiquimod 5% cream. Clin Exp Dermatol. Jul 2008;33(4):454-6. [Medline].

27. Tritton SM, Smith S, Wong LC, Zagarella S, Fischer G. Pyogenic granuloma in ten children treated with topical imiquimod. Pediatr Dermatol. May-Jun 2009;26(3):269-72. [Medline].

28. Maloney DM, Schmidt JD, Duvic M. Alitretinoin gel to treat pyogenic granuloma. J Am Acad Dermatol. Dec 2002;47(6):969-70. [Medline].

29. Ceyhan AM, Basak PY, Akkaya VB, Yildirim M, Kapucuoglu N. A case of multiple, eruptive pyogenic granuloma developed on a region of the burned skin: can erythromycin be a treatment option?. J Burn Care Res. Sep-Oct 2007;28(5):754-7. [Medline].

30. Parisi E, Glick PH, Glick M. Recurrent intraoral pyogenic granuloma with satellitosis treated with corticosteroids. Oral Dis. Jan 2006;12(1):70-2. [Medline].

31. Tursen U, Demirkan F, Ikizoglu G. Giant recurrent pyogenic granuloma on the face with satellitosis responsive to systemic steroids. Clin Exp Dermatol. Jan 2004;29(1):40-1. [Medline].

32. Daya M. Complete resolution of a recurrent giant pyogenic granuloma on the palm of the hand following single dose of intralesional bleomycin injection. J Plast Reconstr Aesthet Surg. Mar 2010;63(3):e331-3. [Medline].

33. Bedard MS, Boulanger J. Treatment of lobular capillary hemangioma with the Nd:YAG laser: retrospective case series of 25 patients. J Cutan Med Surg. May-Jun 2009;13(3):181-2. [Medline].

34. Sud AR, Tan ST. Pyogenic granuloma-treatment by shave-excision and/or pulsed-dye laser. J Plast Reconstr Aesthet Surg. Jul 20 2009;[Medline].

35. Holbe HC, Frosch PJ, Herbst RA. Surgical pearl: ligation of the base of pyogenic granuloma--an atraumatic, simple, and cost-effective procedure. J Am Acad Dermatol. Sep 2003;49(3):509-10. [Medline].

36. Mirshams M, Daneshpazhooh M, Mirshekari A, Taheri A, Mansoori P, Hekmat S. Cryotherapy in the treatment of pyogenic granuloma. J Eur Acad Dermatol Venereol. Aug 2006;20(7):788-90. [Medline].

37. Azzopardi EA, Xuereb CB, Iyer S. Pyogenic granuloma as a surrogate indicator of deep seated foreign bodies: a case report. Cases J. Aug 5 2009;2:7354. [Medline].

38. Allen RK, Rodman OG. Pyogenic granuloma recurrent with satellite lesions. J Dermatol Surg Oncol. Jun 1979;5(6):490-3. [Medline].

39. Cooper PH, McAllister HA, Helwig EB. Intravenous pyogenic granuloma. A study of 18 cases. Am J Surg Pathol. Jun 1979;3(3):221-8. [Medline].

40. Cooper PH, Mills SE. Subcutaneous granuloma pyogenicum. Lobular capillary hemangioma. Arch Dermatol. Jan 1982;118(1):30-3. [Medline].

41. Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis. Oral Surg Oral Med Oral Pathol. Aug 1991;72(2):196-9. [Medline].

42. Eng AM, Hong HY. Recurrent pyogenic granulomas: a form of lobular capillary hemangioma. Cutis. Aug 1993;52(2):101-3. [Medline].

43. LeBoit PE. Lobular capillary proliferation: the underlying process in diverse benign cutaneous vascular neoplasms and reactive conditions. Semin Dermatol. Dec 1989;8(4):298-310. [Medline].

44. Manus DA, Sherbert D, Jackson IT. Management considerations for the granuloma of pregnancy. Plast Reconstr Surg. May 1995;95(6):1045-50. [Medline].

45. Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma. A study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol. Oct 1980;4(5):470-9. [Medline].

46. Mooney MA, Janniger CK. Pyogenic granuloma. Cutis. Mar 1995;55(3):133-6. [Medline].

47. Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol. Dec 1997;37(6):887-919; quiz 920-2. [Medline].

48. Shah M, Kingston TP, Cotterill JA. Eruptive pyogenic granulomas: a successfully treated patient and review of the literature. Br J Dermatol. Nov 1995;133(5):795-6. [Medline].

49. Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. Jul 1996;41(7):467-70. [Medline].

50. Taira JW, Hill TL, Everett MA. Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol. Aug 1992;27(2 Pt 2):297-300. [Medline].

51. Wilson BB, Greer KE, Cooper PH. Eruptive disseminated lobular capillary hemangioma (pyogenic granuloma). J Am Acad Dermatol. Aug 1989;21(2 Pt 2):391-4. [Medline].

Sumber :http://emedicine.medscape.com/article/1084701-overview#showall

Dermatologic Manifestations of Pyogenic Granuloma (Lobular Capillary Hemangioma) Clinical Presentation

Author: Joseph C Pierson, MD; Chief Editor: Dirk M Elston, MD

Updated: Apr 29, 2010

History Physical Causes Show All

Multimedia LibraryReferences

History

The common solitary pyogenic granuloma (lobular capillary hemangioma) grows rapidly to its maximum size over a period of a few weeks.

Patients with pyogenic granuloma may report a glistening red lesion that bleeds spontaneously or after trauma. A history of trauma preceding the onset of the pyogenic granuloma may be elicited. Untreated pyogenic granulomas eventually atrophy, become fibromatous, and slowly regress.

The head, neck, digits, and upper trunk are affected most commonly.

A few reports of lesions developing in a preexisting nevus flammeus or spider angioma exist. Pyogenic granuloma has also been reported to develop at the site of a cherry angioma treated with pulsed-dye laser.[3]

Systemic retinoids may occasionally trigger pyogenic granuloma–like lesions. These occurred more frequently just after the approval of isotretinoin. In current practice, a lower initial dose is used and this phenomenon is unusual. Several reports have described pyogenic granulomas occurring with the use of topical retinoids.[4]

The use of indinavir, a protease inhibitor, has been associated with the development of pyogenic granulomas, predominantly of the great toes.[5] In addition, pyogenic granuloma–like lesions developing during erythropoietin treatment[6, 7] and systemic chemotherapy with 5-fluorouracil,[8] capecitabine (a fluoropyrimidine),[9] mitoxantrone,[10] docetaxel,[11] , and epidermal growth factor receptor inhibitor[12] have all been documented.

The pregnancy tumor variant most often occurs in the second or third trimester.

Rare multiple pyogenic granuloma lesions may be grouped or eruptive and disseminated in nature. Congenital disseminated pyogenic granulomas have been reported.[13]

Eruptive disseminated pyogenic granulomas have developed following a drug hypersensitivity reaction.[14]

Adolescents and young adults are more prone to develop multiple recurrent lesions after prior attempts at removal, especially on the trunk.

Physical

The typical solitary pyogenic granuloma (lobular capillary hemangioma) is a bright red, friable polypoid papule or nodule ranging from a few millimeters to several centimeters (average size is 6.5 mm). Bleeding, erosion, ulceration, and crusting frequently are noted. Regressing lesions appear as a soft fibroma. The head and neck (specifically the gingiva, lips, nasal mucosa, and face), distal extremities (especially the fingers) are the sites of predilection, but lesions occur anywhere on the integument. Note the images below.

Pyogenic granuloma on the neck of the young girl. Courtesy of

Jeffrey P. Callen, MD. Multiple recurrent pyogenic granulomas on

the neck of a young girl. Courtesy of Jeffrey P. Callen, MD. Pyogenic granuloma on the hand. Courtesy of Jeffrey P. Callen, MD.

The pregnancy tumor variant of pyogenic granuloma most frequently is found along the maxillary intraoral mucosal surface, but any intraoral, perioral, and nonoral tissue may be involved.

Pyogenic granuloma with satellitosis, a subcutaneous subtype, and a disseminated variant have been described. The majority of satellites occur on the trunk, often around the scapula.

A 25-cm giant pyogenic granuloma has been reported at the site of a scar in an HIV-positive patient.[15]

The subcutaneous subtype of pyogenic granuloma is commonly found on the upper extremity. A rare intravenous pyogenic granuloma variant may present as a vascular polyp on the neck or upper extremities.

Causes

The cause of the typical pyogenic granuloma (lobular capillary hemangioma) is not known. Trauma, hormonal influences, Bartonella species seropositivity, viral oncogenes, underlying microscopic arteriovenous malformations, production of angiogenic factors, and cytogenetic clonal deletion abnormalities[16] have all been implicated. While trauma was long considered a primary cause, one large study found only 7% of patients had a history of preceding trauma.[17] One study found no association between pyogenic granuloma and infection with Bartonella species.[18]

Development of the lesion in the setting of systemic and topical retinoid,[19] indinavir protease inhibitor, 5-fluorouracil, capecitabine (a fluoropyrimidine), mitoxantrone, docetaxel,[11] , epidermal growth factor receptor inhibitor, and erythropoietin.[6, 7] therapies has been documented (see History), but this phenomenon is not completely understood.

1. Chen SY, Takeuchi S, Urabe K, et al. Overexpression of phosphorylated-ATF2 and STAT3 in cutaneous angiosarcoma and pyogenic granuloma. J Cutan Pathol. Aug 2008;35(8):722-30. [Medline].

2. Alexander AM Jr, Koh JK. Granuloma pyogenicum (pyogenic granuloma) causing severe anemia. Arch Dermatol. Jul 1972;106(1):128. [Medline].

3. Cheah S, DeKoven J. Pyogenic granuloma complicating pulsed-dye laser therapy for cherry angioma. Australas J Dermatol. May 2009;50(2):141-3. [Medline].

4. Teknetzis A, Ioannides D, Vakali G, Lefaki I, Minas A. Pyogenic granulomas following topical application of tretinoin. J Eur Acad Dermatol Venereol. May 2004;18(3):337-9. [Medline].

5. Bouscarat F, Bouchard C, Bouhour D. Paronychia and pyogenic granuloma of the great toes in patients treated with indinavir. N Engl J Med. Jun 11 1998;338(24):1776-7. [Medline].

6. Suarez-Amor O, Cabanillas M, Monteagudo B, de Las Heras C, Cacharron JM. [Disseminated pyogenic granuloma induced by erythropoietin?]. Actas Dermosifiliogr. Jun 2009;100(5):439-40. [Medline].

7. Vergara A, Isarria MJ, Rodriguez-Peralto JL, Guerra A. [Disseminated lobular capillary hemangiomas]. Actas Dermosifiliogr. Jul-Aug 2008;99(6):494-6. [Medline].

8. Curr N, Saunders H, Murugasu A, Cooray P, Schwarz M, Gin D. Multiple periungual pyogenic granulomas following systemic 5-fluorouracil. Australas J Dermatol. May 2006;47(2):130-3. [Medline].

9. Piguet V, Borradori L. Pyogenic granuloma-like lesions during capecitabine therapy. Br J Dermatol. Dec 2002;147(6):1270-2. [Medline].

10. Freiman A, Bouganim N, O'Brien EA. Case reports: mitozantrone-induced onycholysis associated with subungual abscesses, paronychia, and pyogenic granuloma. J Drugs Dermatol. Jul-Aug 2005;4(4):490-2. [Medline].

11. Devillers C, Vanhooteghem O, Henrijean A, Ramaut M, de la Brassinne M. Subungueal pyogenic granuloma secondary to docetaxel therapy. Clin Exp Dermatol. Mar 2009;34(2):251-2. [Medline].

12. Segaert S, Van Cutsem E. Clinical signs, pathophysiology and management of skin toxicity during therapy with epidermal growth factor receptor inhibitors. Ann Oncol. Sep 2005;16(9):1425-33. [Medline].

13. Browning JC, Eldin KW, Kozakewich HP, Mulliken JB, Bree AF. Congenital disseminated pyogenic granuloma. Pediatr Dermatol. May-Jun 2009;26(3):323-7. [Medline].

14. Palmero ML, Pope E. Eruptive pyogenic granulomas developing after drug hypersensitivity reaction. J Am Acad Dermatol. May 2009;60(5):855-7. [Medline].

15. Nthumba PM. Giant pyogenic granuloma of the thigh: a case report. J Med Case Reports. Mar 31 2008;2:95. [Medline].

16. Truss L, Dobin SM, Donner LR. Deletion (21)(q21.2q22.12) as a sole clonal cytogenetic abnormality in a lobular capillary hemangioma of the nasal cavity. Cancer Genet Cytogenet. Oct 1 2006;170(1):69-70. [Medline].

17. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol. Dec 1991;8(4):267-76. [Medline].

18. Levy I, Rolain JM, Lepidi H, et al. Is pyogenic granuloma associated with Bartonella infection?. J Am Acad Dermatol. Dec 2005;53(6):1065-6. [Medline].

19. Campbell JP, Grekin RC, Ellis CN, Matsuda-John SS, Swanson NA, Voorhees JJ. Retinoid therapy is associated with excess granulation tissue responses. J Am Acad Dermatol. Nov 1983;9(5):708-13. [Medline].

20. Jose RM, Bennett A, Holmes J. Spitz naevi presenting as pyogenic granulomata. Br J Plast Surg. Oct 2005;58(7):1037-9. [Medline].

21. Zaballos P, Llambrich A, Cuéllar F, Puig S, Malvehy J. Dermoscopic findings in pyogenic granuloma. Br J Dermatol. Jun 2006;154(6):1108-11. [Medline].

22. Zaballos P, Rodero J, Serrano P, Cuellar F, Guionnet N, Vives JM. Pyogenic granuloma clinically and dermoscopically mimicking pigmented melanoma. Dermatol Online J. Oct 15 2009;15(10):10. [Medline].

23. Vega Harring SM, Niyaz M, Okada S, Kudo M. Extramedullary hematopoiesis in a pyogenic granuloma: a case report and review. J Cutan Pathol. Sep 2004;31(8):555-7. [Medline].

24. North PE, Waner M, Mizeracki A, Mihm MC Jr. GLUT1: a newly discovered immunohistochemical marker for juvenile hemangiomas. Hum Pathol. Jan 2000;31(1):11-22. [Medline].

25. Fallah H, Fischer G, Zagarella S. Pyogenic granuloma in children: treatment with topical imiquimod. Australas J Dermatol. Nov 2007;48(4):217-20. [Medline].

26. Georgiou S, Monastirli A, Pasmatzi E, Tsambaos D. Pyogenic granuloma: complete remission under occlusive imiquimod 5% cream. Clin Exp Dermatol. Jul 2008;33(4):454-6. [Medline].

27. Tritton SM, Smith S, Wong LC, Zagarella S, Fischer G. Pyogenic granuloma in ten children treated with topical imiquimod. Pediatr Dermatol. May-Jun 2009;26(3):269-72. [Medline].

28. Maloney DM, Schmidt JD, Duvic M. Alitretinoin gel to treat pyogenic granuloma. J Am Acad Dermatol. Dec 2002;47(6):969-70. [Medline].

29. Ceyhan AM, Basak PY, Akkaya VB, Yildirim M, Kapucuoglu N. A case of multiple, eruptive pyogenic granuloma developed on a region of the burned skin: can erythromycin be a treatment option?. J Burn Care Res. Sep-Oct 2007;28(5):754-7. [Medline].

30. Parisi E, Glick PH, Glick M. Recurrent intraoral pyogenic granuloma with satellitosis treated with corticosteroids. Oral Dis. Jan 2006;12(1):70-2. [Medline].

31. Tursen U, Demirkan F, Ikizoglu G. Giant recurrent pyogenic granuloma on the face with satellitosis responsive to systemic steroids. Clin Exp Dermatol. Jan 2004;29(1):40-1. [Medline].

32. Daya M. Complete resolution of a recurrent giant pyogenic granuloma on the palm of the hand following single dose of intralesional bleomycin injection. J Plast Reconstr Aesthet Surg. Mar 2010;63(3):e331-3. [Medline].

33. Bedard MS, Boulanger J. Treatment of lobular capillary hemangioma with the Nd:YAG laser: retrospective case series of 25 patients. J Cutan Med Surg. May-Jun 2009;13(3):181-2. [Medline].

34. Sud AR, Tan ST. Pyogenic granuloma-treatment by shave-excision and/or pulsed-dye laser. J Plast Reconstr Aesthet Surg. Jul 20 2009;[Medline].

35. Holbe HC, Frosch PJ, Herbst RA. Surgical pearl: ligation of the base of pyogenic granuloma--an atraumatic, simple, and cost-effective procedure. J Am Acad Dermatol. Sep 2003;49(3):509-10. [Medline].

36. Mirshams M, Daneshpazhooh M, Mirshekari A, Taheri A, Mansoori P, Hekmat S. Cryotherapy in the treatment of pyogenic granuloma. J Eur Acad Dermatol Venereol. Aug 2006;20(7):788-90. [Medline].

37. Azzopardi EA, Xuereb CB, Iyer S. Pyogenic granuloma as a surrogate indicator of deep seated foreign bodies: a case report. Cases J. Aug 5 2009;2:7354. [Medline].

38. Allen RK, Rodman OG. Pyogenic granuloma recurrent with satellite lesions. J Dermatol Surg Oncol. Jun 1979;5(6):490-3. [Medline].

39. Cooper PH, McAllister HA, Helwig EB. Intravenous pyogenic granuloma. A study of 18 cases. Am J Surg Pathol. Jun 1979;3(3):221-8. [Medline].

40. Cooper PH, Mills SE. Subcutaneous granuloma pyogenicum. Lobular capillary hemangioma. Arch Dermatol. Jan 1982;118(1):30-3. [Medline].

41. Daley TD, Nartey NO, Wysocki GP. Pregnancy tumor: an analysis. Oral Surg Oral Med Oral Pathol. Aug 1991;72(2):196-9. [Medline].

42. Eng AM, Hong HY. Recurrent pyogenic granulomas: a form of lobular capillary hemangioma. Cutis. Aug 1993;52(2):101-3. [Medline].

43. LeBoit PE. Lobular capillary proliferation: the underlying process in diverse benign cutaneous vascular neoplasms and reactive conditions. Semin Dermatol. Dec 1989;8(4):298-310. [Medline].

44. Manus DA, Sherbert D, Jackson IT. Management considerations for the granuloma of pregnancy. Plast Reconstr Surg. May 1995;95(6):1045-50. [Medline].

45. Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma. A study of 73 cases from the oral and nasal mucous membranes. Am J Surg Pathol. Oct 1980;4(5):470-9. [Medline].

46. Mooney MA, Janniger CK. Pyogenic granuloma. Cutis. Mar 1995;55(3):133-6. [Medline].

47. Requena L, Sangueza OP. Cutaneous vascular proliferation. Part II. Hyperplasias and benign neoplasms. J Am Acad Dermatol. Dec 1997;37(6):887-919; quiz 920-2. [Medline].

48. Shah M, Kingston TP, Cotterill JA. Eruptive pyogenic granulomas: a successfully treated patient and review of the literature. Br J Dermatol. Nov 1995;133(5):795-6. [Medline].

49. Sills ES, Zegarelli DJ, Hoschander MM, Strider WE. Clinical diagnosis and management of hormonally responsive oral pregnancy tumor (pyogenic granuloma). J Reprod Med. Jul 1996;41(7):467-70. [Medline].

50. Taira JW, Hill TL, Everett MA. Lobular capillary hemangioma (pyogenic granuloma) with satellitosis. J Am Acad Dermatol. Aug 1992;27(2 Pt 2):297-300. [Medline].

51. Wilson BB, Greer KE, Cooper PH. Eruptive disseminated lobular capillary hemangioma (pyogenic granuloma). J Am Acad Dermatol. Aug 1989;21(2 Pt 2):391-4. [Medline].

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