Pyogenic granulomaL98.0

Common, mostly after minor injuries, but also spontaneously developing, rapidly exophytic, benign vascular tumor of the skin and mucous membranes close to the skin.

Clinical and histological classification:

• Classic granuloma pyogenicum
• Epulis gravidarum of the gingiva
• Subcutaneous and intravascular granuloma pyogenicum (histological diagnosis)
• Disseminated (eruptive) granuloma pyogenicum (multiple small mostly aggregated nodules)
• Granuloma pyogenicum with satellitosis (especially in children and young adults; recurrent tumor with synchronous flare-up of multiple satellite nodules)

Frequently occurring after banal injury, with subsequent development of excessive, vascularized granulation tissue; more common during pregnancy. Apparently BRAF and RAS mutations play a role in the pathogenesis of this "reactive" and therefore benign tumor. Granulomata pyogenica are also frequently observed with isotretinoin.

Common during pregnancy (epulis gravidarum of the gingiva) with postpartum involution.

Age of first manifestation: rare in the 1st year of life; most common in the 2nd-5th decade of life.

Mainly lips, scalp, face, fingertips, tongue, palm and toes, less frequently localizations in the area of the oral mucosa. An esophageal localization has been described (Suarez-Zamora DA et al. 2018).

1.0-3.0 cm in size, rarely larger, solitary, soft, spherical, slightly bleeding, red, blue, or black, sharply demarcated papule (nodule).

Usually absent to little pain.

As it grows, there is usually constriction of the base, which is bordered by the epidermis in a collar-like fashion. The surface is often eroded, weeping, later ulcerated, and possibly covered with a bled-in black crust.

Differentiate "uncomplicated" granuloma pyogenicum from (rare) bacterial nailfold angiomatosis, which is more likely to be associated with reactive granulation tissue in unguis incarnatus.

Also belonging to the lobular capillary hangiomas of the granuloma pyogenicum type are the rare eruptive disseminated cases (satellitosis), which may occur after incomplete removal of the "primary tumor". In these cases, osseous destruction has also been described. In this respect, the dignity of this rare form of manifestation remains questionable.

Exophytic, multilobular, mature cell (CD31+) capillary tumor in papillary and reticular dermis. Absent or only thin epithelial covering. Numerous small or larger vascular spaces with clusters of erythrocytes. In the upper parts of the tumor, there is often a vigorous accompanying inflammatory reaction with neutrophilic granulocytes and lymphocytes in the presence of edematous connective tissue stroma. In sections, especially in the deeper parts, also solid tumor nodules with only a few vascular spaces. Numerous mitoses (Ki-67 positivity is significantly increased), moderate endothelatypia. In late stages widened septa with regressed vascular parenchyma.

Great tendency to ulceration with bleeding tendency. If left untreated, granuloma pyogenicum may shrink after several months. A soft fibromatous papule remains as a relic. The recurrence rate after incomplete removal is high.

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