A school age child presents with a lesion on their cheek that has been oozing blood for the past several hours. The parents noted a small red bump several weeks prior to presentation, but he says that it just started bleeding in class. The school officials were freaked out and called an ambulance – mom and dad meet you in the ED and this is what you see.

This lesion is known as a pyogenic granuloma. Interestingly it is not a granuloma – instead a lobular capillary hemangioma. It is also not pyogenic – there’s no pus – and the cause is not related to injury or infection. They most commonly appear on the face, and are seen in children with a female predominance. At first they can be small – fewer than a few millimeters. They can grow rapidly and exceed a few centimeters. They are particularly fragile, and often bleed without provocation. At first they are intensely red due to capillary proliferation, later achieving a pinker hue. They can also be seen on the oral mucosae and gingiva, and are especially noteworthy as a cause of nosebleeds if they occur in the nasal septum. In pregnant women they often appear in the third trimester and have thus achieved the nickname granuloma gravidarum.

The treatment for a bleeding pyogenic granuloma starts with pressure. This will stop bleeding in most cases, but the lesion will still be friable. Because 3/5 pediatric cases appear on the face cosmetic concerns certainly exist when it comes to therapy. That’s why I find it hard to recommend cauterizing with silver nitrate in a willy-nilly fashion if the bleeding has stopped. I would only recommend applying silver nitrate to very small (definitely subcentimeter) lesions and applying EMLA beforehand. Other treatments used by dermatologists and plastic surgeons (which are not available/practical in the Pediatric Emergency Department) include:

  • Shave removal with electrocautery
  • Primary excision
  • Pulse-dye laser

One study indicated that shave excision was faced with a recurrence rate of almost 40%. If you are at all concerned about the cosmetic outcome it is best to refer.