Dermcase: A positive Band-Aid sign in a toddler

May 1, 2009

A toddler comes into the office with a hemorrhagic red papule.

» How would you treat him?

» What's the diagnosis?

Pyogenic granuloma is a common benign vascular tumor of the skin and mucous membrane that can present at any age.

Common sites include the face, gingiva, lips, and fingers, but any site can be involved. Pyogenic granuloma most commonly occurs in women during and following pregnancy and among healthy toddlers (boys and girls, although there is a slight female predominance in some series.1)

Clinical findings

Pathogenesis

Although the cause is unknown, pyogenic granuloma may follow minor injuries such as scratches, insect bites, burns, scalds, excisional surgery, and liquid nitrogen therapy. There may also be a tendency for these tumors to develop in pre-existing vascular lesions, including port wine stains, salmon patches, and spider angiomas.2 They evolve quickly over two to three weeks, and accidental trauma often triggers bleeding.

Differential diagnosis

Pyogenic granulomas are most commonly misdiagnosed as hemangiomas, but the onset after the newborn period and course are not consistent with hemangiomas of infancy. Cherry angiomas usually develop in middle-aged adults, but occasionally lesions first appear in adolescence. Dark purple or brown pyogenic granulomas may be mistaken for pigmented nevi, and possibly malignant melanoma.

Pathology

Histopathologic findings reveal a lobular hemangioma. However, the underlying pathology is often obscured by overlying ulceration. Pyogenic granulomas can be distinguished from granulation tissue, but may be confused with Kaposi's sarcoma.

Treatment

Without treatment, most lesions persist. Superficial cautery with silver nitrate may result in a temporary cessation of bleeding, but recurrence after minor trauma frequently occurs.

Although some surgeons advocate excision, the risk of recurrence is significant. Simple shave and electrodessication after infiltration with lidocaine with epinephrine is 100% successful in uncomplicated pyogenic granulomas in toddlers.2 There may be a role for the yellow flashlamp-pulsed tuneable dye laser in selected patients, but several treatments are usually required.3

DR. COHEN is section editor for Dermatology: What's your Dx?, and is director, Pediatric Dermatology and Cutaneous Laser Center, and professor of pediatrics and dermatology, Johns Hopkins University School of Medicine, Baltimore.

The author has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article. Vignettes are based on real cases that have been modified to allow the authors and editor to focus on key teaching points. Images may also be edited or substituted for teaching purposes.

References

1. Patrice SJ, Wiss K, Muliken J: Pyogenic granuloma (lobular hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol 1991;8:267

2. Pagliai KA, Cohen BA: Pyogenic granuloma in children. Pediatr Dermatol 2004;21:10

3. Tay YK, Weston WL, Morelli JG: Treatment of pyogenic granuloma in children with the flashlamp-pumped pulsed dye laser. Pediatrics 1997;99:368