Pyogenic granuloma

The pyogenic granuloma (lat pyogenic granuloma ) is an acquired benign vascular skin tumor from the group of hemangiomas. It is an exophytic vascular proliferation.

This highly proliferating tumor ( hyperplasia ) is frequently misdiagnosed as a malignant tumor ( cancer). The pyogenic granuloma has no specific histological appearance. Therefore, in the past, it was given a variety of names, including granuloma pediculatum, pediculatum, granulomatous epulis, Pyogenic granuloma, epulis angiomatosa, Wundgranulom, stem tubers, Pyogenicum, Pseudobotryomykom, teleangiektatisches Wundgranulom, eruptive angioma and proliferating Angioma.

The widespread term pyogenic granuloma is a misnomer ( Misnomer ), because it is not an infectious bacterial nature ( = pyogenic, pus forming '), but is an inflammatory hyperplasia. Even the term granuloma is actually wrong.

Therefore, some authors prefer the term lobular capillary hemangioma (English lobular capillary hemangioma, LCH ), while other authors distinguish two subspecies pyogenic granuloma at: lobular capillary hemangioma and said a non- LCH - type (non- LCH). Both subtypes differ in their histology.

Distribution and incidence

The pyogenic granuloma can occur in both men and women in each age group. Heaped in the second and third age decade it occurs. In fair-skinned people, the prevalence is 86.4 percent, considerably higher than among black ( 6.2 percent ) and Asian ( 0.8 percent).

Since the pyogenic granuloma often occurs during pregnancy, it is called in these cases, pregnancy tumor ( granuloma gravidarum 'or epulis gravidarum ). The altered during a pregnancy hormone levels of women increase the likelihood of lobular capillary hemangioma of the training. Very different points from 0.2 to about 14% are for the prevalence of pregnancy tumor, depending on the study, stated.

The pyogenic granuloma is a skin tumor. Very rarely found in the gastrointestinal tract - with the exception of the oral cavity. The incidence of oral pyogenic granulomas is very high.

Etiology

The exact pathomechanism leading to a pyogenic granuloma, is still largely unknown. Local irritation, traumatic injury, certain medicines, or even hormonal changes are in principle to initiate tumor formation in the situation.

Many patients report that they used to have an injury or irritation at the point at which they have one pyogenic granuloma has formed. For example, can develop after a circumcision pyogenic granulomas. Even second-degree burns may years later favor the development of pyogenic granulomas same location. Wine stains ( nevus flammeus ) are often to be observed starting point for a pyogenic granuloma. Obviously, the malformed blood vessels in port-wine stain favor their formation. Longer time is thought to have human papillomaviruses would play a role in the genesis of pyogenic granuloma. Using polymerase chain reaction, no viruses of the HPV types 6, 11, 16, 31, 33, 35, 42 or 58, however, could be detected.

The inducible NO synthase ( iNOS), the Vascular Endothelial Growth Factor ( VEGF), fibroblast growth factor (FGF ) and the Connective Tissue Growth Factor ( CTGF ) play an essential role in angiogenesis and the growth of a pyogenic granuloma.

During pregnancy, complex, not yet fully understood, changes in the blood vessels take place. In addition to a pyogenic granuloma araneus nevi ( Spinnennaevi ), glomus tumors or edema are formed (especially on the face and legs ), for example increased. Most of these phenomena are formed after the end of the pregnancy back - even granuloma gravidarum ( pregnancy tumor). Poor oral hygiene during pregnancy significantly increases the probability for a pyogenic granuloma. In many cases it is possible - for different reasons - during pregnancy, oral hygiene after, so that increasingly can form tartar among others. Gingivitis get about 35 to 50 percent of all pregnant women during their pregnancy.

Certain medications, such as first-generation retinoids ( isotretinoin ) for the treatment of acne, are suspected to cause pyogenic granulomas in certain cases.

Description

Typical of the pyogenic granuloma are the rapid growth of the tumor with formation of a red node, which is cut off in the course of growth towards the base ( mushroom-shaped structure). The diameter is in most cases from 10 to 30 mm. The tumor is rarely larger and usually occurs only individually. A satellitosis is very rarely observed. To healthy tissue, there is a sharp demarcation. The surface of most soft spherical tumor is rugged and crusty, as they are easily prone to oozing or bleeding in many cases. In the late stage of tumor tends to secondary ulcerations. The tumor itself usually causes no pain.

Preferably, pyogenic granuloma forms on the extremities, the head and neck area and the oro - nasal mucous membranes. Accordingly, it is often on the lips, scalp, face, found on fingers, tongue, palm and toes. Occasionally may be affected also the penis. A pregnancy tumor arises, however, almost exclusively in the oral cavity.

Very rarely there is a pyogenic granuloma in other organs such as liver, small intestine, stomach of the sigmoid colon (the last section of the large intestine) or at all in the gastrointestinal tract.

Spontaneous regressions (Back formations ) - with the exception of pregnancy tumor ( granuloma gravidarum ) - very rare. Incomplete removal of the recurrence rate is very high.

Subtypes

There are several rare subtypes of pyogenic granuloma known. These include:

• Subcutaneous intravascular variant
• The eruptive pyogenic granuloma and
• The pyogenic granuloma with satellitosis.

Differential Diagnosis

The pyogenic granuloma can be from amelanotic malignant melanoma ( a special form of melanomas ) differ only histologically. Also a hemangiosarcoma, and - especially in the oral cavity - a squamous must also be taken into consideration. Squamous cell carcinomas are about 80 percent, the most common malignant tumors in the oral cavity.

Therapy

As a pyogenic granuloma - with the exception of the tumor pregnancy - is not resolved in the most cases, the removal of the tumor is appropriate in many cases. This can be done surgically by excision or by laser ablation. In both cases it is important that the central blood vessel that feeds the tumor is completely removed, otherwise it is very often found to recur. Some authors recommend because of the high recurrence rate of the laser ablation. The relapse rate is the excision of the region of up to 15 percent. Recurrences can get back on the original tumor size a few days after therapy. Excision can be performed under local anesthesia in adults. In children, usually a general anesthetic is applied.

In addition to these two established procedures were performed in the past nor the cryosurgery, intralesional injection of corticosteroids, ethanol and other sclerosing substances used or discussed.

Forecast

A pyogenic granuloma is due to its benignity usually not a serious illness. After the complete removal of the tumor, there is a very high probability of complete healing.

There are cases of pregnancy tumors known to have formed on the nasal mucosa, the entire nasal cavity filled out and then grew out of the nose. The patients then lost in bleeding up to 500 ml of blood. Due to the extreme tumor growth parts of the nasal skeleton and paranasal sinuses can degenerate.

First description

Pyogenic granuloma described in 1897 for the first time the French Antonin Poncet and Dor Louis in a patient who had this tumor in the oral cavity. They called the disease Botryomycosis hominis because they thought there were a transmitted from horses to humans Botryomycose (grape fungal disease ); a chronic wound infection. Seven years later, found MB Hartzell, that this assumption was wrong. He gave the disease the still the most used - incorrect - name pyogenic granuloma.