Evidence-based answers from the Family Physicians Inquiries Network

Ari Gilmore, MD; Gary Kelsberg, MD; What’s the best treatment Sarah Safranek, MLS Valley Family Medicine, Renton, Wash (Drs. Gilmore for pyogenic granuloma? and Kelsberg); and University of Washington Health Sciences Library, Seattle (Ms. Safranek)

EVIDENCE-BASED ANSWER

it’s difficult to say which therapy, which may require multiple ses- A treatment is best, since most studies sions, and sclerotherapy may be least likely don’t compare treatments directly. Pros and to cause visible scarring (strength of recom- cons vary. Simple surgical excision is asso- mendation [SOR]: C, small cohort studies ciated with a low risk of recurrence, but of- and case series). Simple surgical ten leaves a visible scar. Curettage or shave Untreated pyogenic granulomas re- excision is excision, with cautery, is more likely to suc- gress spontaneously within 6 to 18 months associated with ceed in 1 session than cryotherapy; both with some risk of scarring (SOR: C, a subset a low risk of may leave a smaller scar than surgery. Laser of patients in a retrospective cohort study). recurrence but often leaves a visible scar. Evidence summary binations of curettage, shave, and cautery Little evidence directly compares treatments (the lesions weren’t diff erentiated by removal for pyogenic granuloma. Most studies ex- method or location). Investigators didn’t re- amine multiple treatment methods without port on residual scarring with any method. comparing results statistically, combine data However, expert opinion states that surgical from adults and children, or comprise case excision often results in a conspicuous linear series using a single treatment method. Th e scar.2 TABLE summarizes outcomes for diff erent therapies. Surgery vs laser therapy or no treatment Another retrospective cohort study described Surgical excision: Low recurrence, treatment, recurrence rate, residual scarring, but scarring is common and patient satisfaction in 76 patients with A retrospective cohort study audited recur- pyogenic granuloma (mean age 6 years; range rence rates in 408 patients (mean age 41 years, 4 months to 17 years). Outcomes were as- range 5 months to 90 years) whose pyogenic sessed by telephone follow-up.3 granulomas were treated with either surgical Fifty-eight lesions were removed by surgi- excision or combinations of curettage, shave, cal excision and cautery with no recurrences and cautery.1 Investigators identifi ed cases (55% of patients had subtle scarring). Nine le- of histopathologically confi rmed pyogenic sions were treated with pulsed dye laser (33% granuloma over a 10-year period from a hos- recurrence, 44% subtle scarring); 3 lesions

pital database. Th irty-six percent of granu- were removed by CO2 laser (100% recurrence, lomas were located on the head and neck, 33% subtle scarring). Four patients were fol- 33% on the arm, 15% on the trunk, and 8% on lowed but not treated (no explanation given); the leg. all untreated pyogenic granulomas disap- Of 326 lesions treated with surgical exci- peared spontaneously within 6 to 18 months sion, 4 (3.7%) recurred. Th e overall recurrence with no recurrences; 1 patient had subtle rate was 10.3% for 82 lesions removed by com- scarring.

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40_JFP0110 40 12/21/09 12:05:20 PM TABLE How treatment outcomes for pyogenic granuloma compare

Treatment Treatment Studies Total patients sessions Recurrence Scarring

Surgical excision 2 retrospective cohort studies1,3 384 1 0%-3.7% 55%

Curettage or 1 retrospective cohort study,1 118 1-2 10% 31% shave excision 1 prospective cohort study4 (average 1.03) with cautery

Cryotherapy 1 prospective cohort 175 1-3 Unknown 42% study,4 1 case series5 (average 1.5)

CO2 laser 1 retrospective cohort 103 1 2%-100% 12%-33% study,3 1 case series6

Pulsed dye laser 1 retrospective cohort 31 1-6 9%-33% 9%-44% study,3 1 case series7 (average 2.25)

Sclerotherapy 1 case series2 9 1 0% “Inconspicuous”

Expectant 1 retrospective cohort study3 4 None 0% 25% management TK

Cryotherapy may require CO2 laser usually removes more treatments than curettage lesions in 1 session A prospective trial randomized 89 patients Another case series of 100 patients (mean age (mean age 34 years; range 11-88 years) with 27 years; range 6 months to 84 years) treated

pyogenic granulomas that were 1.5 cm or with CO2 laser reported that the pyogenic smaller to receive either curettage or cryother- granuloma was removed completely in 1 ses- apy, then evaluated the number of treatments sion in 98 patients. Twelve percent of patients required and whether scarring occurred. had visible scarring and another 10% had Follow-up was 85%.4 slight textural skin changes. All patients re- A single curettage resolved pyogenic ported satisfaction with the results.6 granuloma in 35 of 36 patients (97%); 9 of the 36 patients (31%) had residual scarring. Pulsed dye laser works for small lesions Twenty-fi ve of 40 pyogenic granulomas (63%) A case series of 22 patients (mean age responded to 1 cryotherapy treatment, 13 le- 3.4 years; range 6 months to 16 years) treated sions (32%) resolved after 2 treatments, and with pulsed dye laser for mostly small lesions 2 (5%) resolved after 3 treatments; 17 of the (average diameter 4 mm) on the face report- 40 patients (42.5%) had a residual scar. Curettage ed successful removal in 20 children in 1 to required fewer treatments overall than cryothera- 6 treatment sessions (average 2.25) with no py (P<.001), but no signifi cant diff erence in resid- residual scarring. Two children with larger ual scarring was noted between the 2 treatments. lesions required shave excision with cautery A case series reported on 135 patients (scarring was not assessed).7 (mean age 26 years; range 4 months to 70 years) whose pyogenic granulomas were Sclerotherapy: treated with cryotherapy.5 Seventy-eight (58%) No recurrence, inconspicuous scars had complete resolution with 1 session, 30% A case series reported results in 9 patients needed 2 sessions, 8% needed 3 sessions, and (median age 18 years; range 1-57 years) with 5% needed 4 sessions (mean 1.58 sessions). pyogenic granuloma treated with a single in- Ninety-four percent had an excellent cosmet- jection of the sclerosing agent monoethanol- ic result (including 12% with a small fl at scar); amine oleate.2 All lesions disappeared without 5% had residual hypopigmentation. recurrence; the authors described remaining

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41_JFP0110 41 12/21/09 12:05:24 PM scars as inconspicuous. One patient reported standard pediatric textbook recommends sur- residual pain lasting 4 weeks after injection gical excision with or without cautery, adding of the sclerosing agent into a 1.5 cm × 1.0 cm that small pyogenic granuloma lesions (<5 mm) pyogenic granuloma that hadn’t responded to may be removed with pulsed dye laser.9 previous cryotherapy. An online textbook recommends either excision or shave (with or without curettage), but advises surgical excision with histologic Recommendations confi rmation for pyogenic granuloma lesions A standard dermatology textbook recommends that can’t be diff erentiated with certainty from curettage with cautery, and reports that sponta- amelanotic melanoma, which typically grows neous regression is common after 6 months.8 A more slowly.10

References 1. Giblin AV, Clover AJP, Athanassopoulos A, et al. Pyogenic granu- 6. Raulin C, Greve B, Hammes S. Th e combined continuous-wave/ loma—the quest for optimum treatment: audit of treatment of pulsed carbon dioxide laser for treatment of pyogenic granuloma. 408 cases. J Plastic Reconstr Aesthet Surg. 2007;60:1030-1035. Arch Dermatol. 2002;138:33-37. 2. Matsumoto K, Nakanishi H, Seike T, et al. Treatment of pyogenic 7. Tay YK, Weston WL, Morelli JG. Treatment of pyogenic granu- granuloma with a sclerosing agent. Dermatol Surg. 2001;27:521- loma with the fl ashlamp-pumped pulsed dye laser. Pediatrics. 523. 1997;99:368-370. 8. Habif TF. Vascular tumors and malformations. In: Habif TF. Clini- 3. Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr cal Dermatology: A Color Guide to Diagnosis and Th erapy. 4th ed. Dermatol. 2004;21:10-13. St. Louis: Mosby; 2004:814-833. 4. Ghodsi SZ, Raziei A, Taheri M, et al. Comparison of cryotherapy 9. Kliegman RM, Nelson WE. Vascular disorders—benign acquired. and curettage for the treatment of pyogenic granuloma: a ran- In: Kliegman RM, Behrman RE, Jenson HB, et al. Nelson Textbook domized trial. Br J Dermatol. 2006;154:671-675. of Pediatrics. 18th ed. Philadelphia: Saunders; 2007:2667-2674. 5. Mirshams M, Daneshpazhooh M, Mirshekari A, et al. Cryo- 10. Goldstein BG, Goldstein AO. Benign neoplasms of skin (section therapy of pyogenic granuloma. J Eur Acad Dermatol Venereol. on pyogenic granuloma). UpToDate [online database]. Version 2006;20:788-790. 17.2: Waltham, Mass: UpToDate; May 2009.

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