jurnal granuloma kulit kendal

8/10/2019 Jurnal Granuloma Kulit Kendal

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Pyogenic Granulomaauthor heading Author: Brett Steinberg, DO; Chief Editor: Dirk M Elston, MD

Background

Pyogenic granulomas (PGs) are benign vascular lesions that occur mostcommonly on the acral skin of children.[1, 2] The term pyogenic granuloma

is a misnomer. Originally, these lesions were thought to be caused by

bacterial infection; however, the etiology has not been determined. The

histopathologic appearance is fairly characteristic; the lesion is, in fact, a

lobular capillaryhemangioma.[3]

Recognition of pyogenic granuloma as a clinically polypoid or exophytic

circumscribed lesion is of importance to the clinician and pathologist

because this feature distinguishes pyogenic granulomas from most

malignant vascular tumors. Although pyogenic granulomas may bemultiple (especially on the skin) and necrosis is common, invasion of

adjacent structures is not observed. The lesions grow rapidly and are

extremely vascular, frequently bleeding either spontaneously or after

minor trauma.[4]

They are usually easily treated with surgical removal but

may recur.

Uncommon variants include pyogenic granuloma with satellitosis,[5, 6, 7]

intravenous pyogenic granulomas,[8] subcutaneous pyogenic

granulomas,[9, 10] and eruptive pyogenic granulomas.[11, 12, 13] Satellite

lesions of smaller pyogenic granulomas may develop at the same time asthe primary lesion or may occur after attempted treatment of the primary

lesion. See the images below.

Pyogenic granulomas are usually solitary lesions. The fingers and hands

are common locations for these to develop. A history of minor trauma at

the site shortly before development of the lesion is frequent.
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Pyogenic granulomas usually bleed with little or no trauma. This patient

shows a positive bandage sign. Because the lesions bleed so easily,patients frequently present with a bandage covering the site.

Pyogenic granulomas usually have a distinct margin that consists of a rim

of keratin (dry skin). Notice the moist area of skin produced by the

bandage, which was removed shortly before the photograph was taken.

Pyogenic granulomas may be pedunculated and quite large. An area of

necrosis is also common.
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Pyogenic granulomas may occur at various sites. More than 60% of all

lesions develop on the head and neck.

Small pyogenic granuloma.

PathophysiologyAlthough most patients (74.2%) do not have a history of trauma or

predisposing dermatologic conditions, in many cases, a history of recent

trauma at the site is present. Large numbers of lesions may occur

following damage to diffuse areas skin by burns or other trauma.[14, 15]

A

nitric oxide synthasedependent mechanism is thought to contribute toangiogenesis and the rapid growth of pyogenic granulomas. They are

benign vascular proliferations, but the specific pathophysiology of these

lesions is unknown.

Epidemiology

Frequency

United StatesPyogenic granulomas account for 0.5% of skin lesions in infants and

children and are also found in the oral mucosa in 2% of pregnant women.

Mortality/MorbidityMost pyogenic granulomas are asymptomatic except for mild tenderness

and a tendency to bleed with little or no trauma. They are benign andeasily treated. Rarely, pyogenic granulomas in unusual sites such as the
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intestines may result in significant bleeding[16, 17, 18]

or other major

complications.[19]

Race

No substantial difference in incidence is found between races.

SexOne study of 178 patients younger than 17 years reported the male-to-

female ratio as 3:2.[20] In adults, pyogenic granulomas are more common

in females because of pregnancy-related lesions.

AgePyogenic granulomas are most common in the first 5 years of life.

[21]

History

Patients with pyogenic granulomas (PGs) usually seek care because the

lesion has grown rapidly and bleeds easily. Patients or parents may beconcerned because the lesion bleeds with little or no trauma; they are

frequently concerned that the rapid growth and bleeding may indicate a

malignancy.

Important questions include the following:

Does the history include trauma at the site prior to development of thelesion? Pyogenic granulomas may occur following minor physical

trauma or burns.

How long has the lesion been present? Most pyogenic granulomasdevelop rapidly. The mean duration at the time of diagnosis is

approximately 3 months. If the lesion has been present longer than6 months, the possibility of cutaneous malignancy increases.

Does the lesion bleed easily? Almost all pyogenic granulomas bleedeasily. If the lesion does not bleed with light rubbing, a diagnosis

of pyogenic granuloma is unlikely.

What therapy has been used recently? Nevi, warts, or other lesions mayhave been treated with caustic agents or cryotherapy prior to

referral. Such therapy may markedly change the appearance of theoriginal lesion, causing it to mimic a pyogenic granuloma.

Is the patient pregnant? Oral pyogenic granulomas can develop duringor just after the first trimester of pregnancy. Examine and properly

identify these lesions of pregnancy to avoid misdiagnosis and

overtreatment. These lesions are not generally harmful in

pregnancy; however, induction of labor due to uncontrollable

bleeding from a gingival lesion has been reported.[22, 23, 24, 25, 26, 27]

Has the lesion recurred after surgical treatment? If so, was it excisedand the skin closed primarily or was it treated with shave removal

and electrodesiccation of the base? Pyogenic granulomas may

recur. This is more likely when they are incompletely removed, butrecurrence is also possible after apparently complete removal.


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Pyogenic granulomas are more likely to recur after shave removal

and electrodesiccation of the base than after surgical excision.

Has the patient taken oral retinoid therapy (isotretinoin [Accutane])recently? Facial pyogenic granulomalike lesions during

isotretinoin therapy have been reported.

PhysicalPyogenic granulomas appear as smooth firm nodules, with

or without crusts, and they may have a bright or dusky red color. They

are usually solitary, well circumscribed, dome shaped, 1-10 mm in

diameter, and sessile or pedunculated.

In children, pyogenic granulomas are most commonly

located on the head and neck (62.4%) and, in order of decreasing

frequency, on the trunk (19.7%), upper extremity (12.9%), and lowerextremity (5%). Most (88.2%) occur on the skin, and the rest involve

mucous membranes of the oral cavity and conjunctivae.

In pregnant women, pyogenic granulomas are most often

found on the gingival mucosa[24, 28]

but they have been known to appear

in nonoral areas such as the fingers and inguinal crease.

Pyogenic granulomas may occur within a port-wine stain;

the presence of a vascular birthmark in the region of the pyogenic

granuloma may be significant.

Amelanotic melanoma may closely mimic a pyogenic

granuloma in appearance. Closely examine the skin immediatelyadjacent to the lesion for any pigmentary irregularity.

CausesOriginally, pyogenic granulomas were thought to be caused

by bacterial infection; the etiology has yet to be determined. Postulated

etiologies include viral, hormonal, and, more recently, angiogenic factors.

Pyogenic granulomas have been evaluated for the presenceof human papillomavirus (HPV)because warts occur in similar age

groups and sites. Lesions were tested for HPV 6, 11, 16, 31, 33, 35, 42,and 58. No viruses were present.

Recurrent pyogenic granuloma with satellitosis is an uncommon

variant. In one patient with recurrent pyogenic granuloma with

satellitosis, Warthin-Starry staining of the lesions revealed clumps of

dark bacilli as found in patients with bacillary angiomatosis.[5]

An indirect

immunofluorescence assay showed elevated immunoglobulin G

antibodies against Bartonella (Rochalimaea) henselae. The patient did

not present an obvious risk for human immunodeficiency virus (HIV)

infectionor immunosuppression; no antibodies against HIV-1 and HIV-2
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were found. Recurrent pyogenic granulomas with satellitosis may be a

localized variant of bacillary angiomatosis.

Procedures

Obtain a biopsy of any lesion suspected of being a pyogenic granuloma(PG) to confirm the diagnosis.

Histologic FindingsProliferation of capillaries is present, with prominent endothelial cells

embedded in edematous gelatinous stroma in a characteristic lobular

configuration (see image below).

Inline figure

Histologic image showing epidermal erosion and crusting, thinned

epidermis, vascular proliferation, and mixed inflammation withlymphocytes, histiocytes, and neutrophils. Courtesy of MedscapeDermatology.

The epidermis is commonly eroded.

A dense infiltrate and granulation tissue with polymorphonuclear

leukocytes may be present.

Hyperproliferation of the epidermis is usually present at the margins of

the vascular growth, which results in a collarette of epidermis.[29, 20, 30]

Surgical Care

Treatment of pyogenic granulomas (PGs) most commonly consists of

shave removal and electrocautery or surgical excision with primary

closure.[31] Removal of the lesion is indicated for bleeding due to trauma,

discomfort, cosmetic distress, and diagnostic biopsy. The lesion may be

completely removed during biopsy.

For solitary lesions, a shave excision and electrocautery under local

anesthesia is the treatment of choice. To provide an adequate cure rate, all

vascular granulation tissue must be removed or cauterized.For large or recurrent lesions, surgical excision with primary closure may
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be more effective. One study reported a 43.5% recurrence rate in 23

lesions treated by shave (intradermal) excision and cautery or cautery

alone. Lesions treated by full-thickness skin excision and linear closure

did not recur.

Therapy with the pulsed-dye laser at vascular-specific 585 nm is veryselective, usually requires no anesthesia, and produces excellent cosmetic

results.[32, 33] The pulsed-dye laser works quite well for intraoral pyogenic

granulomas, as observed in pregnant women. Although treatment is

feasible, treatment during pregnancy is not necessary because the lesions

may recur during the pregnancy and generally resolve with delivery.

Various other lasers have also been shown to be effective in treating

pyogenic granulomas.[34, 35, 36, 37]

Cryotherapy or silver nitrate therapy may be effective for very small

lesions and exhibited a low overall recurrence rate (1.62%). However, ifnonsurgical management is undertaken, cauterization with silver nitrate

should be the first-line treatment.[38, 39, 40]

In pediatric cases, a eutectic mixture of local anesthetics (EMLA) applied

to the lesion and surrounding skin under an occlusive dressing for 1-2

hours prior to additional intralesional anesthesia may be of significant

value.

New treatment options may include topical treatment with imiquimod 5%

cream. It is a synthetic imidazoquinoline heterocyclic amine that

enhances, through cytokine induction, both the innate and acquired

immune pathways, resulting in immunomodulating, antiviral, andantitumor effects.[40, 41, 42] Definitive data on its efficacy and safety on

pediatric age groups are not established, but there are different case

reports about its use in the treatment of molluscum contagiosum,

anogenital warts, hemangiomas, and, recently, pyogenic granuloma.[43]

Treatment results were satisfactory with minimal scarring, and adverse

effects were similar to those observed in adult patients.[44]

Consultations

Consider referral to a dermatologist if the diagnosis is in doubt or ifthe availability of adequate therapy is questionable.

Medication Summary

Despite the necrosis, foul odor, and purulent drainage noted

occasionally with pyogenic granulomas (PGs), antibiotic therapy is rarely

required.


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Further Outpatient Care

Following removal of the pyogenic granuloma (PG), routine woundcare is the only treatment required.

Follow-up visits are required only if the lesion recurs. If the lesion

recurs and histopathology confirms the diagnosis, the recurrentlesion may be treated with any of the modalities previously

discussed, including simply repeating the initial therapy.

ComplicationsSignificant secondary infection (extremely uncommon)

Recurrence at the original site

Recurrence as multiple satellite lesions in the area

immediately surrounding the original lesion

Superficial scar formationOral pyogenic granulomas

An oral pyogenic granulomas can develop during or just after the

first trimester of pregnancy.

Usually, an oral pyogenic granulomas is an early slow-growing mass

that, upon excision, does not leave a large defect in the periodontium

that requires surgical repair.

Rarely, a rapidly growing large tumor may produce significant

hemorrhage.

PrognosisPrognosis is excellent after simple removal and wound care.


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