The term pyogenic granuloma is a misnomer. The lesion is not related to bacterial infection nor is it a granuloma. The lesion also is known as a granuloma telangiectaticum. It results from capillary proliferation usually following localized trauma to the skin. On biopsy, there is a predominance of capillaries lined with endothelial cells accompanied by various amounts of acute and chronic inflammatory infiltrates.
Pyogenic granulomas are fairly common, particularly in women during pregnancy. In fact, they have been referred to as “pregnancy tumors.” While they can arise on any mucosal or skin area, the most common spots are the fingers, toes, lips, gingiva, and upper trunk. They range in size from 5 mm to 10 mm in diameter. They are pedunculated, and appear reddish or black. The lesion is friable, and often it is the frequent bleeding that causes the patient to seek medical care. In the patient presented here, a small, steady stream of blood one to two feet in length projected from the lesion when she cleaned the debris from its surface. It was easily managed by compression.
There are interesting case reports in the literature describing unusual presentations of this granuloma. One of interest was in an elderly man who presented with the chief complaint of melena for three weeks. He was admitted, and had an esophagogastroduodenoscopy performed, which identified a 30 mm-diameter lesion arising from the gastric mucosa that was later confirmed by pathology to be a pyogenic granuloma.
These lesions develop fairly rapidly over a period of weeks. While often associated with trauma and hormonal factors, they can arise spontaneously, but they generally do not spontaneously regress. While it may be tempting to remove this in the ED, it is not advised because of the vascularity of the lesion. Shave excision with cauterization by a dermatologic surgeon is preferred. As with most lesions, it should be sent to pathology to eliminate the possibility of malignancy. The differential diagnosis for pyogenic granulomas includes irritated nevus, seborrheic keratosis, malignant melanoma, and imbedded ticks. Once removed, the lesion should not recur.
The development of pyogenic granulomas during pregnancy is only one of many skin changes that may occur during pregnancy. Normal physiologic changes that may be seen during pregnancy can be divided into changes in pigmentation, changes in blood vessels, and changes in connective tissue.
It is unclear why, but almost all women experience some hyperpigmentation during pregnancy. Areas of the skin, in particular, the areola, axilla, groin, perineum, and upper thighs may darken. Preexisting lesions such as nevi and freckles also may darken. Many women also will experience a change in the pigmentation of the linea alba. This is the tendinous median line on the anterior abdominal wall between the two rectus muscles. As it darkens, the term linea nigra is used.
Probably the most concerning pigment changes for women involve hyperpigmentation in the face, or melasma. This also is referred to as the mask of pregnancy. The distribution can vary and is often categorized into one of three patterns. The centrofacial pattern involves pigmentary changes of cheeks, forehead, upper lip, and chin. The malar pattern involves only the cheeks and nose. The mandibular pattern involves the ramus of the mandible. These changes usually subside within a year, and patients should be advised to stay out of the sun because this can worsen the discoloration.
Estrogen and other factors result in dilation and proliferation of blood vessels as presented above. Another common change observed during pregnancy is the development of vascular spiders. These appear as red branching lesions extending from a central puncta. Patients also may present with various degrees of palmar erythema. This, too, will subside after delivery. Finally, the dreaded development of varicosities may occur. These can be seen not only in the lower extremities but also in vulvar and anal areas.
The last normal changes of the skin that occur during pregnancy involve the connective tissue. The most common clinical manifestations include stretch marks and skin tags. Stretch marks, striae distensae, or striae gravidarum appear as pink or purplish linear patches on the abdomen, breasts, upper legs and arms, and back. They usually fade postpartum, but unfortunately never disappear. Almost anyone you talk to will mention a surefire way to prevent them, but they appear to be linked most closely with genetics. Skin tags (molluscum fibrosum gravidarum) occur most commonly on the face, neck, axilla, chest, groin, and inframammary region. These also often regress after pregnancy.