Abstract
Pyogenic granuloma (PG) is a benign vascular proliferative tumor of the skin and mucous membranes, it can appear spontaneously or following triggering factors. Different clinical aspects are described, pyogenic granulomas following burns (GB) are rare. We report a case of post-burn pyogenic granuloma confirmed by histological study and treated surgically. This new observation will allow us to further clarify this condition.
Keywords: Pyogenic granuloma, burn
Introduction
Pyogenic granuloma (PG) is a benign vascular proliferative tumor of the skin and mucous membranes [1,2], first described by Poncet and Dor in 1897 [3]. Several denominations are used to describe it (Table 1) [2]. Post-burn pyogenic granulomas (PBG) are quite rare: they often occur after a second-degree burn. Their diagnosis is essentially clinical in children. In adults, other tumors may mimic PGB, mainly Kaposi’s sarcoma, angiosarcoma, squamous cell carcinoma [4]. We report a new case of multiple post-burn GP treated surgically.
Table 1.
Nomenclature of pyogenic granuloma [2]
| Name |
|---|
| Botryomycosis hominis |
| Granuloma telangietodes |
| Granuloma pediculatum benignum |
| Granuloma telangiectaticum pediculatum |
| Pseudobotryomycosis |
| Granuloma telangiectaticum |
| Granuloma pyogenicum |
| Fibroangioma |
| Hartzell disease |
| Bloody wart |
| Septic granuloma |
| Hemangiomatous granuloma |
| Lobular capillary hemangioma |
| Eruptive capillary hemamgioma |
Case report
A 9-month-old girl consulted for skin tumors of the abdomen that had evolved 10 days earlier, following superficial second-degree scalding burns. On clinical examination, the child presents with 2 limited exophytic sessile ulcerated lesions, bleeding at touch, located on a pink atrophic burn scar. The diagnosis of localized post-burn eruptive PG was made and confirmed histologically after full-thickness surgical excision (Figure 1) and primary closure (Figure 2). No microbiological study was done before surgery, there was no clinical infection.
Figure 1.
Postburn pyogenic granuloma of the abdomen before treatment. A: Front view, B: ¾ view.
Figure 2.
Surgical treatment by excision and suture in 2 planes.
Discussion
GP represents 0.5% of cutaneous nodules in children. It can be cutaneomucosal or visceral, single or multiple [4]. Various factors are incriminated in its occurrence: increased levels of female sex hormones; inflammatory diseases; infections and medications [1-3,5].
Pyogenic granulomas following burns (PGB) are different from classic pyogenic granulomas [4-9]:
○ PGB patients have an initial burn.
○ Most PGBs develop an acute eruption between 1 and 4 weeks after the burn.
○ PGBs may be infected by bacteria, fungi and viruses.
○ PGBs have three main histological characteristics: hyperkeratosis, numerous newly formed proliferative vascularizations, and edematous stromata with inflammatory and plasma cells.
Infectious agents may also play the role of a secondary stimulus in the initiation of PGBs, several germs have been found in patients with PGBs [6,10]. Burn patients are easily superinfected, however, the reasons why only few patients develop PGB are unclear.
Different treatments are used including conservative treatment, which is usually different from that of classical pyogenic granuloma (therapeutic abstention with oral antibiotic therapy: erythromycin 40 mg/kg): electrocoagulation, cryotherapy, laser, shaving, surgery [2,10].
Because PGBs can involve the reticular dermis, pulsed dye lasers, cauterization, and shaving may not be able to reach the total PG, and these modalities have a 43.5% recurrence rate [2]. Definitive treatment requires full-thickness skin excision [10].
Only 29 cases of PGB have beeń reported in the literature [6,11,12]. Most often, lesions appear 1 to 4 weeks after the occurrence of second-degree thermal burns by mostly hot liquids (Table 2).
Table 2.
General data on post-burn pyogenic granuloma
| Authors | Origin country | cases | Age/sex | Burn agent | Depth of burns | Appear time after burns |
|---|---|---|---|---|---|---|
| De kaminsky et al. [6] (1978) | Argentiae | 1 | 15 month/F | Boiling milk | 2 | 1 week |
| Momeni et al. [7] (1995) | Iran | 3 | 1, 5 year/M | Boiling milk | 2 and 3 | 2 weeks |
| 5 years/F | Boiling milk | 2 | 2 weeks | |||
| 35 years/F | Boiling milk | 2 | 2 weeks | |||
| Ceyhan et al. [8] (1997) | Turkey | 1 | 18 month/F | Boiling milk | 2 | 1 week |
| Liao et al. [13] (2006) | China | 2 | 41 years/M | Boiling water | 2 | 20 days |
| 19 years/M | Boiling water | 2 | 9 days | |||
| Aliağaoğlu et al. [14] (2006) | Turkey | 1 | 5 years/F | Not mentioned | 2 | 2 weeks |
| Bozkurt et al. [15] (2006) | Turkey | 1 | 2 years/M | Boiling milk | 2 | 8 weeks |
| Diallo et al. [16] (2006) | Senegal | 3 | 8 month | Thermal burn | 2 | Not mentioned |
| 13 month | 2 | Not mentioned | ||||
| 13 years | 2 | Not mentioned | ||||
| Ceyhan et al. [17] (2007) | Turkey | 1 | 17 month/M | Boiling water | 2 | 2 weeks |
| Shirol et al. [18] (2012) | india | 1 | 42 ans/F | Not mentioned | 2 | 1 year |
| Durgun et al. [9] (2013) | Turkey | 2 | 18 month/F | Boiling milk | 2 | 29 days |
| 7 years/M | Boiling milk | 2 | 2 weeks | |||
| Zhao et al. [11] (2015) | China | 5 | 4 years/M | Thermal burn | 2 | Not mentioned |
| 15 month/M | 2 | |||||
| 3 years/F | 2 | |||||
| 26 month/F | 2 | |||||
| 2 years/F | 2 | |||||
| Dastgheib et al. [19] (2016) | Iran | 1 | 12 years/M | Boiling milk | 2 | 2 weeks |
| Xu et al. [20] (2016) | China | 1 | 4 years/F | Boiling Soup | 2 | 30 days |
| Ashk Torab et al. [21] (2018) | Iran | 1 | 15 month/F | Boiling water | 2 | 10 days |
| Mansoul et al. [4] (2018) | Algérie | 1 | 3 years/M | Boiling water | 2 | 10 days |
| Iraji et al. [22] (2021) | Iran | 1 | 30 years/F | Boiling oil | 3 | 4 weeks |
| Mezdour et al. [12] (2021) | Algeria | 2 | 28 years/M | Petrol | 2 | 20 days |
| 47 years/F | petrol | 2 | 20 days | |||
| Keshavarzi et al. [23] (2021) | Iran | 1 | 49 years/F | Boiling water | deep | 2 weeks |
Nineteen of the 29 cases were children under 9 years old, with a slight female predominance (sex ratio: 0.93).
The geographical origin of the reported cases may be of interest. No case has been described in Europe or North America. On the other hand, 8 cases out of 29 have been described in China, 7 in Iran, and 6 in Turkey.
The treatment choice depended on several factors, especially the location and the number of lesions. 27.5% of the patients reported (8/29) had surgical excision, 65.5% (19/29) had conservative treatment, and 10.3% (3/29) regressed spontaneously (Table 3).
Table 3.
Treatment of pyogenic granulomas
| Authors | Localisation of PGB | Number of lesions | Treatement |
|---|---|---|---|
| De kaminsky et al. [6] (1978) | Face, trunk, arms | Not mentioned | electrocoagulation |
| Momeni et al. [7] (1995) | Face, neck, back and thigh Abdomen and thigh | 28 lesions | Therapeutic abstention |
| Face | 65 lesions | Electrocoagulation of 2 lesions + abstention of the rest | |
| 90 lesions | Therapeutic abstention | ||
| Ceyhan et al. [8] (1997) | Face, trunk, arms | Not mentioned | Excision + suture |
| Liao et al. [13] (2006) | Face, left forearm | Non mentionnés | topical antibiotic |
| Front, back and upper limb | More than 9 lesions | topical and oral antibiotics | |
| Aliağaoğlu et al. [14] (2006) | arm | 2 lesions | Excision + suture |
| Bozkurt et al. [15] (2006) | Left upper limb | 5 lesions | Excision + suture |
| Diallo et al. [16] (2006) | Not mentioned | Not mentioned | Therapeutic abstention |
| Ceyhan et al. [17] (2007) | arm | Multiple lesions | Oral antibiotic |
| Shirol et al. [18] (2012) | chin | 1 lesion | Excision + graft |
| Durgun et al. [9] (2013) | Face and neck | Multiple lesions | Excision + suture |
| forearm | 7 confluent lesions | Excision + total skin graft | |
| Zhao et al. [11] (2015) | Face and neck | Multiple lesions | antibiotic |
| Arm and handbras | |||
| Back and buttocks | |||
| hand | |||
| Dastgheib et al. [19] (2016) | Lower limbs | Multiple lesions | No follow up |
| Xu et al. [20] (2016) | Left arm and elbow | Multiple lesions | Chinese herbal medicine |
| Ashk Torab et al. [21] (2018) | Back | Multiple lesions | Plant application |
| Mansoul et al. [4] (2018) | Left buttock | 6 lesions | Topical beta-blocker |
| Iraji et al. [22] (2021) | forearm | Multiple lesions | Antibiotic + excision + electrocoagulation |
| Mezdour et al. [12] (2021) | Left forearm | Multiple lesions | Topical beta-blocker |
| Less extensive | Topical beta-blocker | ||
| Keshavarzi et al. [23] (2021) | hand | Not mentioned | Excision + thin skin graft |
In our patient, the epidemiologic and clinical features are similar to the cases reported in the literature. The choice of surgical treatment was made in view of the local skin laxity and the possibility of primary closure without major scarring. This one-time treatment was preferred to other modalities: laser, coagulation, antibiotic therapy, etc., for the rapidity of the result. No reccurence evolved at 6 months follow-up.
Conclusion
PGB lesions are benign based on clinical features and histological examinations. Several successful methods have been used to treat pyogenic granuloma but surgery when possible represents the most reliable way of local control.
Disclosure of conflict of interest
None.
References
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