The Case
A concerned mom presents with her daughter who has the following lesion on her left cheek that has enlarged over the past month and today wouldn’t stop bleeding at daycare. It started as a red dot a few months back and has grown steadily.
What is it?
This is a pyogenic granuloma, which are neither pyogenic, nor granulomas. This is another example of something getting a name a long time ago that does not describe the lesion now that more is known about it. These lesions are benign vascular lesions that grow fast and become friable. They may be more appropriately called lobular capillary hemangiomas. They can be confused with cutaneous abscesses, melanoma, hemangioma, nevi, matrixomas and more. They may result from local trauma or certain medications (topical retinoids would be the most common in kids) – but the cause is generally unknown. They often come to our attention in the ED because they won’t stop bleeding. Which leads us to the next section…
What if they won’t stop bleeding in the ED?
Gentle pressure will likely have already been applied at home, but this is obviously the first step. You’ll want to hold pressure for 10-15 minutes. Consider adaptic, xeroform or another dressing that won’t stick to the lesion at the base, as the friability may lead to return of bleeding if the dressing is pulled off. If pressure doesn’t work consider application of a topical vasoconstrictor (like LET). You may want to combine the vasoconstrictor with pressure initially.
Next in line would be a prothrombotic dressing like QuikClot, Celox or Surgicel. These are chemicals impregnated into a gauze like material that can temporize bleeding.
I would recommend avoiding the use of silver nitrate in the ED without discussing with a plastic surgeon. Ultimately lesions can ulcerate and this can complicate manners. Additional sclerotherapy involves direct injection of 1-2 mL of 1% sodium tetradecyl sulfate into the vascular plexus. This is not readily done in the Pediatric Emergency Department. Other options include excision, electrodesiccation, curettage, chemical cauterization, and lasers.
Topical beta blockers – like timolol – have been recently used in pyogenic granuloma treatment. Per Win Lee et al. in a small series of patients topical timolol lead to improvement over two to three months.
Here are some other examples of pyogenic granulomas
References
Lee et al. Treatment options for cutaneous pyogenic granulomas: A review. J Plast Reconstr Aesth Surg. 2011; 64(9): 1216-1220.
Pagliai et al. Pyogenic granuloma in children. Pediatr Dermatol, 2004 Jan-Feb;21(1):10-3.
