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 Table of Contents  
BRIEF REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 30-33

Successful Treatment of Pyogenic Granuloma with Sclerotherapy


1 Department of Dermatology, Venereology and Leprology, RNT Medical College, Udaipur, Rajasthan, India
2 Department of Skin and VD, BJ Medical College, Pune, Maharashtra, India
3 Department of Dermatology, Government Medical College, Miraj, Maharashtra, India
4 Department of Dermatology, KLE Academy of Higher Education and Research's, JN Medical College, Belagavi, Karnataka, India

Date of Web Publication22-Jul-2019

Correspondence Address:
Dr. Vasudha A Belgaumkar
Department of Skin and V. D, B. J. Medical College, Pune - 411 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdd.ijdd_6_19

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  Abstract 


Pyogenic granuloma (PG) is a common benign vascular proliferation that usually occurs on the skin and mucosa. Various treatment options exist in literature with no clear consensus. Our objective was to evaluate the efficacy and safety of sclerotherapy (sodium tetradecyl sulfate [STS]) in PG. This case series included 15 patients of PG, treated with intralesional injection of the STS (3%, 30 mg/ml) solution. All patients showed complete resolution of PG, without any major complication or recurrence during a 6-month follow-up period.

Keywords: Pyogenic granuloma, sclerotherapy, sodium tetradecyl sulfate


How to cite this article:
Bansal N, Belgaumkar VA, Chavan RB, Doshi BR. Successful Treatment of Pyogenic Granuloma with Sclerotherapy. Indian J Drugs Dermatol 2019;5:30-3

How to cite this URL:
Bansal N, Belgaumkar VA, Chavan RB, Doshi BR. Successful Treatment of Pyogenic Granuloma with Sclerotherapy. Indian J Drugs Dermatol [serial online] 2019 [cited 2019 Aug 18];5:30-3. Available from: http://www.ijdd.in/text.asp?2019/5/1/30/263103




  Introduction Top


Pyogenic granuloma (PG) is a benign localized proliferation of capillaries appearing as a solitary red or purple nodule with a tendency to bleed. It may rapidly grow in response to an unknown stimulus that triggers endothelial proliferation. Treatment modalities for PG range from surgical excision, marsupialization, cryosurgery, laser surgery, to intralesional injections of sclerosing agents. When the PG is large or in surgically difficult areas, choosing an appropriate treatment modality can be challenging. Excision can lead to disfigurement and scar formation; lasers may not be suitable for bulky lesions besides the cost of instrumentation and proper training. A relatively high rate of recurrence after simple excision is known. As sclerotherapy is a simple, safe, effective, and minimally invasive procedure, with negligible blood loss and no specific postoperative care, it has evolved as an effective alternative approach.[1],[2]

Sclerotherapy makes use of wide variety of sclerosants such as polidocanol, sodium tetradecyl sulfate (STS), sodium morrhuate, sodium sylliate, pingyangmycin, OK-432, ethanolamine oleate, and ethanol. This case series includes 15 patients of PG treated with STS solution (Setrol) (3%, 30 mg/ml). Till date, only a few reports involving a small number of subjects are available in the literature, documenting the use of sclerotherapy for this indication.


  Materials And Methods Top


Over a period of January 2015–2016, 15 patients of PG were treated with sclerotherapy after obtaining written and informed consent. Those with cardiac disorders, pregnancy, and lactation were excluded from the study. STS solution (3%, 30 mg/ml) was injected (without dilution and local anesthesia) slowly into the lesion with the help of insulin syringe until lesional blanching. The injection dose ranged from 0.1 to 0.3 ml (mean dose: 0.15 ml) depending on the lesion size. The stalk of pedunculated lesions was clamped and compression was performed with cotton gauge for 1 min postprocedure in all lesions. No bleeding was noted during or after injection. The lesion was observed at least once a week after each session until it became a dry necrotic mass and fell off spontaneously. Follow-up evaluation was performed monthly, up to 6 months.


  Results Top


A total of 15 cases over 1 year period were recruited. Females outnumbered males in a ratio of 2:1. The age of the patients ranged between 6 and 55 years (mean: 30.5 years). The size of these 15 PGs varied between 0.5 and 1.5 cm (mean size: 0.8 cm). Most of the cases had lesions on the lips (six cases) [Figure 1]a and [Figure 1]b followed by three cases each with lesions on the face and scalp and one case each with lesions on finger [Figure 2]a and [Figure 2]b nose, and neck.
Figure 1: (a) Pyogenic granuloma over the lower lip (Case 5). (b) Pyogenic granuloma resolved after two sessions of sclerotherapy

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Figure 2: (a) Pyogenic granuloma over the finger (Case 4). (b) Pyogenic granuloma resolved after one sitting

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One–three treatment sessions at weekly intervals were required to achieve complete resolution [Table 1]. Although statistical analysis was attempted, no correlation was observed between parameters like age, gender, size or site of lesion, and a number of treatment sessions/time to resolution.
Table 1: Summary of 15 patients with pyogenic granuloma treated with sclerotherapy

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In all the 15 patients, sclerotherapy resulted in complete regression of the PG by 3 weeks, with an inconspicuous scar. No complication occurred except in two patients, one of which experienced immediate swelling of the lip after injection [Figure 3]a, [Figure 3]b, [Figure 3]c that resolved after single intramuscular hydrocortisone injection, whereas the second patient developed an atrophic scar at the injection site [Figure 4]a and [Figure 4]b. All except one patient (in whom lesion resolved after the first session) completed the 6-month follow-up period. None of the lesions recurred over this duration.
Figure 3: (a) Pyogenic granuloma over the lip (Case 1). (b) Lip swelling immediate after the first session of scleortherapy. (c) Pyogenic granuloma resolved after two sessions of sclerotherapy

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Figure 4: (a) Pyogenic granuloma over the neck (Case 2). (b) Pyogenic granuloma resolved with scar formation

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  Discussion Top


PG is a benign, acquired, vascular lesion that appears as a solitary red papule. The lesion grows rapidly and may become pedunculated. The surface frequently erodes, leading to bleeding.

A clinicopathological study of 178 cases reported two-thirds of PGs to be located in the head and neck area, the most frequent sites being the cheek, oral cavity, scalp, forehead, eyelid, and lip.[1]

Standard treatment includes full-thickness excision of the skin, including the base of the lesion. Because surgical excision often results in a conspicuous linear scar and general anesthesia is required in infants, conservative treatment is often preferred over excision.

Various conservative treatment methods have been developed over time, including cryotherapy with liquid nitrogen, electrodesiccation, and chemical cauterization. A major drawback of these measures is the high recurrence rate. Shave excision with cautery and cautery alone showed a recurrence rate of 43.5%.[1]

Although the 585-nm flashlamp-pumped pulse dye laser has been reported to be of great benefit,[2] majority required two or three treatment sessions occasionally up to six with a proportionate increase in the cost of therapy. Thus, despite encouraging results with these modalities, proliferating elements within the dermis may persist and lead to recurrence.

Sclerosants can be classified as detergents (STS, sodium morrhuate, polidocanol, and ethanolamine oleate), osmotic agents (hypertonic sodium chloride and hypertonic sodium chloride with dextrose), and chemical irritants (chromated glycerin and polyiodinated iodine). In our cases, STS was selected as sclerosant since it is the only detergent sclerosant approved by the Food and Drug Administration for superficial varicosities. There have also been instances of STS administration in the treatment of varicoceles, vascular malformations of the extremities, upper gastrointestinal bleeding, hemorrhagic tumors, lymphoceles, and percutaneous ablation of oral lesions of Kaposi sarcoma and ganglion cysts.[3] Moreover; it has a very low incidence of allergic reactions, pigmentation, and other adverse cutaneous effects if it extravasates.

Commercially available as 1% and 3% solution, this long-chain fatty acid causes vascular intimal irritation by protein theft denaturation, leading to thrombus formation with eventual occlusion and obliteration of the vessel.[4] In PG, it may irreversibly injure the endothelial cells comprising the major part of the lesion and induce necrosis of the entire lesion, thereby eliminating chances of recurrence.

In the present case series, 100% response rate was achieved with no recurrence. A previous study by Moon et al. of 14 cases treated with the same sclerosant shows the results comparable with our study.[5] Sacchidanand and Purohit and Moon et al. reported a complete resolution of PG in a week, using the same sclerosant in the same concentration and amount in three patients, two with PG over the lip and one over the scalp, without any recurrence during 3-month follow-up period.[6] Rahman has also used STS (3%, 30 mg/ml) in one case of PG over the scalp with a complete resolution in a single sitting and no recurrence during 6-month follow-up.[7] Shah and Ranghani found that the size of lesion determined the number of weekly injections required for complete regression in their eight cases of PG treated with polidocanol.[8] However, no such correlation was identified in our case series. This may be explained by the larger size of individual lesions and greater variation between the dimensions of largest (>4 cm) and smallest lesions (<1 cm) in the above-mentioned study as compared to the present series (0.5–1.5 cm).

Although several complications including acute renal insufficiency and pulmonary embolism have been reported with intravariceal injection of STS, these events have occurred due to high dose of sclerosant, leading to intravascular hemolysis. As blood flow is not high within the PG,[9] we neither anticipated nor encountered such major complications.

Hyperpigmentation has been reported in up to 30% of cases of spider telangiectasias treated with this agent[10] but was not seen in any of our subjects. Other potential local complications, such as Nicolau syndrome which occurs due to inadvertent extravasation of sclerosant in the surrounding tissue, can be prevented by precautions such as clamping of stalk of pedunculated lesion[11] as performed in our patients. The adverse effects such as postinjection swelling and scar may be attributed to inflammatory reaction. This can be further minimized by the application of ice packs during and immediate postprocedure.


  Conclusion Top


Sclerotherapy is effective and safe in the treatment of PG without any recurrences. Its advantages include minimal patient discomfort and relative ease of administration even in a resource-poor setting with no necessity of local anesthesia or elaborate postoperative care. With prudent patient selection and careful injection technique with appropriate amount of agent, this method may become a frontline treatment option for PG, particularly for the larger and poorly accessible lesions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgement

The authors acknowledge Dr. Aarti Salunke for her valuable contribution in patient management and manuscript preparation. Dr. Vasudha Belgaumkar is supported by the Fogarty International Center of the US National Institutes of Health (grant # D43TW00957). The content is solely the responsibility of the authors and does not represent the official views of the NationalnInstitutes of Health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): A clinicopathologic study of 178 cases. Pediatr Dermatol 1991;8:267-76.  Back to cited text no. 1
    
2.
Glass AT, Milgraum S. Flashlamp-pumped pulsed dye laser treatment for pyogenic granuloma. Cutis 1992;49:351-3.  Back to cited text no. 2
    
3.
Albanese G, Kondo KL. Pharmacology of sclerotherapy. Semin Intervent Radiol 2010;27:391-9.  Back to cited text no. 3
    
4.
Saraf S. Role of sodium tetradecyl sulfate in venous malformations. Indian J Dermatol 2006;51:258.  Back to cited text no. 4
  [Full text]  
5.
Moon SE, Hwang EJ, Cho KH. Treatment of pyogenic granuloma by sodium tetradecyl sulfate sclerotherapy. Arch Dermatol 2005;141:644-6.  Back to cited text no. 5
    
6.
Sacchidanand S, Purohit V. Sclerotherapy for the treatment of pyogenic granuloma. Indian J Dermatol 2013;58:77-8.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Rahman H. Pyogenic granuloma successfully cured by sclerotherapy: A case report. J Pakistan Assoc Dermatol 2014;24:361-4.  Back to cited text no. 7
    
8.
Shah JS, Ranghani AF. Sclerotherapy in pyogenic granuloma and mucocele. J Indian Acad Oral Med Radiol 2018;30:230-4  Back to cited text no. 8
    
9.
Matsumoto K, Nakanishi H, Seike T, Koizumi Y, Mihara K, Kubo Y. Treatment of pyogenic granuloma with a sclerosing agent. Dermatol Surg 2001;27:521-3.  Back to cited text no. 9
    
10.
Tretbar LL. Injection sclerotherapy for spider telangiectasias: A 20-year experience with sodium tetradecyl sulfate. J Dermatol Surg Oncol 1989;15:223-5.  Back to cited text no. 10
    
11.
Nirmal B, Segu SS, Sacchidanand SA, Deshpande P. Nicolau syndrome following sclerotherapy for pyogenic granuloma. Indian J Dermatol Venereol Leprol 2014;80:484.  Back to cited text no. 11
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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