Case Study of the Week: Pyogenic Granuloma

Don't you love seeing a strange rash or skin lesion?  Rashes and lesions are one of the few diagnoses you can actually visualize making them all the more interesting.  While pyogenic granulomas aren't particularly complex or difficult to treat, they can look pretty rough.

The other day at work, a patient presented to the emergency department where I work with a large lesion on her finger.  Erythematous and slightly oozing, I had never seen anything like it.  I grabbed one of the physicians I work with for advice on treating this mystery mass.  I was immediately gratified when he took a look at the patient's finger and stepped back.  The look on his face was one of surprise.

True to the ways of modern medicine, he snapped a photo of the finger with his iPhone, texting it to the orthopedist.  "What is this?", the text read.  The orthopedist immediately called us back with reassurance this patient would not loose her finger.  Based on the photo, he suspected the lesion was a very large pyogenic granuloma.  So, what exactly is a pyogenic granuloma and how is it treated?

Case Presentation

A 47 year-old female patient presents to your clinic with an uncomfortable, oozing lesion to her second left finger.  She reports she may have possible scratched the area while working in the yard but isn't sure.  The lesion has increased rapidly in size over the past two days but growth appears to have stabilized today.  The patient denies systemic symptoms including fever and chills.  The patient's vital signs are within normal limits and she has no significant medical history

Upon exam, you note a vascular appearing nodule about one centimeter in diameter on the patient's second left finger.  The lesion bleeds slightly upon palpation.  The area is tender and does not have surrounding erythema.  Based on this patient's clinical presentation, you diagnose her with a pyogenic granuloma.

Management and Outcome

Pyogenic granulomas are caused by an array of factors including trauma, pregnancy and hormonal changes, medications and viral and bacterial infections.  If you suspect medications are the cause, discontinuing use of the offending medication may cause the granuloma to regress.  In pregnant women, the lesion may disappear after delivery.  If the granuloma does not resolve on it's own after removing the causative factor, or if a cause cannot be identified, it can be removed.  

Various methods are used to remove pyogenic granulomas.  Topical Imiquimod been used to successfully treat granulomas.  Alternatively, the lesions can be chemically cauterized with silver nitrate or with photodynamic therapy.  Shaving off the lesion, removing it with punch biopsy or excising the lesion with a scalpel is also effective.  If the granuloma is excised, the entire lesion must be removed to prevent recurrence.  Full-thickness excision has the lowest rate of recurrence.  Use of lasers and cryotherapy may also effectively remove pyogenic granulomas. 

Discussion

Although typically small and uncomplicated, pyogenic granulomas can be disfiguring and uncomfortable.  Nurse practitioners should be able to recognize and treat, or refer, these lesions appropriately to avoid their recurrence and minimize potentially complications such as scarring. 

What have you found to be the most effective treatment for pyogenic granulomas in your practice?

 

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