From time to time in clinic we hear that a red bump has come up on the lip, that it bleeds when it is barely brushed, and that it seems to get a little bigger the more it is touched. One of the lesions we think of in that situation is pyogenic granuloma. The name may be unfamiliar, but it is not an uncommon condition to come across. This article sets out why pyogenic granuloma develops, and what the advantages and the downsides of each treatment are, from surgical excision through to ligation, in which the lesion is tied off with thread.
Three-Line Summary
- Pyogenic granuloma is a benign vascular tumor that commonly develops on the skin and mucous membranes. In dermatology clinics we mainly see it near the fingernails or toenails and on the lips; it bleeds easily with even minor irritation and tends to grow little by little the more it is touched.
- With treatments that remove the lesion directly, such as surgical excision and electrocautery, recurrence tends to be low, but they can leave a scar. Vascular laser and cryotherapy are less invasive, but in exchange the number of sessions tends to go up.
- If the base is narrow, giving a shape that can be tied off with thread, ligation can be considered. Copying this at home with ordinary thread can lead to infection or heavy bleeding, though, so please do not tie it off yourself.
A Red Bump on the Lip: What Kind of Lesion Is Pyogenic Granuloma?
Pyogenic granuloma is a benign vascular tumor that commonly develops on the skin and mucous membranes. In dermatology clinics we mainly see it near the fingernails or toenails and on the lips. It also commonly develops on mucous membranes such as the gums.
From the outside, it looks like a red bump sticking out of the skin. It bleeds easily with even minor irritation, and it tends to grow little by little the more it is touched. As a result, it is unsightly and becomes a nuisance in daily life as well. Even if it bothers you, it is better not to keep touching it.
Many people say it is the first time they have heard the name, yet more people than you might expect come to the clinic after being troubled by this lesion. More familiar benign lesions such as skin tags, seborrheic keratoses and warts are covered separately in our guide to benign tumors and warts.
Why Does Pyogenic Granuloma Develop?
Pyogenic granuloma mainly develops in the following situations.
- A wound that does not heal and repeated irritation — this is when a minor wound lingers without healing, or the same spot is chronically irritated. An ingrown toenail is one example.
- The influence of female hormones — pregnancy, puberty, taking oral contraceptives and the like fall under this.
- Medications — it is sometimes brought on by various medications, including anticancer drugs.
Pyogenic granuloma is what forms when, through causes like these, inflammation persists and blood vessels proliferate excessively.
How We Explain It in Clinic
A wound that started out minor ought to close over, but if it keeps being irritated it cannot. We often explain it as a state in which the tissue at that spot has grown excessively and what was inside has pushed its way out.
Treatments That Remove the Lesion Directly — Surgical Excision and Electrocautery
There are several ways of treating pyogenic granuloma. Cutting it out surgically, repeated vascular laser sessions and electrocautery are in general use, and there are a number of other methods as well. Let us start with the two that remove the lesion directly.
Surgical Excision
Surgical excision is the method regarded as the standard treatment. According to a 2010 literature review that brought several studies together (Gilmore et al., Journal of Family Practice), in a retrospective study that analyzed 408 cases the recurrence rate after surgical excision was 3.7%, lower than when the lesion was scraped off or burned away (10.3%). Its drawback, however, is that it leaves a scar. A study of pediatric patients included in the same review reports that, among patients whose lesions were removed by excision and cautery, more than half, 55%, were left with subtle scarring.
Electrocautery
Electrocautery is a treatment that removes the lesion by burning it away with an electric current, and it is sometimes used after the lesion has been scraped off, to burn the spot where it was. In a 2006 randomized trial (British Journal of Dermatology) that compared cryotherapy with this method of scraping and then burning, 35 of the 36 cases treated with the latter resolved with a single treatment. However, scarring or pigment changes remained in 31%, and in the 408-case study above the recurrence rate after the lesion was scraped off or burned away was 10.3%.
Recurrence Tends to Be Low, but Scarring Is the Concern
Methods like these, which remove the lesion physically, have the advantage that recurrence tends to be low. But the fact that they can leave a scar makes them hard to choose readily in some cases. Since the state of the skin after treatment has to be considered as well, less invasive treatments are often looked at first.
Less Invasive Treatments — Vascular Laser and Cryotherapy
A less invasive treatment means a less aggressive treatment, one that does not cut into or scrape the skin. Vascular laser, topical medication, cryotherapy and ligation belong here. Ligation is explained separately further on; here we look at vascular laser and cryotherapy first.
Vascular Laser
Vascular laser treatment targets the blood vessels that have proliferated in the lesion. A 1064 nm Nd:YAG laser or a pulsed dye laser (PDL) is used. Rather than being finished in one session, though, it is usual to treat several times, and the 1064 nm laser sometimes causes scarring.
Cryotherapy
Cryotherapy treats the lesion by freezing it, and it can be an effective treatment for pyogenic granuloma as well. In the 2006 randomized trial we saw above (British Journal of Dermatology), cryotherapy needed one to three treatments (a mean of 1.42), and scarring or pigment changes remained in 42.5% of the 40 cases. We have explained what kind of treatment cryotherapy is in our article on wart cryotherapy.
The Limitation Both Methods Share
These methods are less invasive, but in exchange they have the drawback that the number of sessions can go up. There are also cases where the response is not sufficient even after several rounds of vascular laser.
If the Shape Can Be Tied Off With Thread — Ligation
Depending on the shape of the lesion, a different method can sometimes help. That method is ligation. It is, quite literally, a treatment that ties the lesion off with thread.
Which Shapes Can Be Tied Off?
Like the lump in the old Korean folktale of the old man with a lump, the lesion has to be narrow at the base and bulge outward. With a shape like this, it can be tied off with medical-grade thread to restrict the blood flow. The part above the tie then drops off, and in some cases it drops off within a day or two after a single treatment.
Another advantage cited is that scarring tends to be less of a concern than with surgical excision or electrocautery. If scarring from surgery or electrocautery worries you and being treated several times feels like a burden, it is worth knowing that this option exists too.
Please Do Not Try This at Home
The principle looks simple, but you should not tie it off at home with ordinary thread. It can lead to infection or to excessive bleeding.
If the Shape Cannot Be Tied Off
For shapes that cannot be tied off, the treatments covered above are combined. Which of the two applies can be known only by checking the shape of the lesion in person.
The Treatments Side by Side
Summed up in a table, what we have covered so far looks like this. Which treatment is suitable depends on the shape of the lesion, and on which weighs on you more, scarring or the number of sessions.
| Treatment | Method | Advantage | Downside |
|---|---|---|---|
| Surgical excision | The lesion is cut out surgically | Recurrence tends to be low | Can leave a scar |
| Electrocautery | Burned away with an electric current | A report of lesions resolving with a single treatment | Can leave a scar, and recurrence is also reported |
| Vascular laser | Targets the blood vessels that have proliferated | Less invasive | Several sessions; the 1064 nm laser sometimes causes scarring |
| Cryotherapy | Treats the lesion by freezing it | Less invasive | Several sessions in some cases, and scarring or pigment changes sometimes remain |
| Ligation | Tied off with medical-grade thread to restrict the blood flow | Sometimes drops off after a single treatment, and scarring tends to be less of a concern | Possible only for shapes that can be tied off |
A Topical Medication Used Alongside — Timolol
On top of these treatments, a topical medication called timolol is sometimes used alongside. Even after the lesion has dropped off, there are cases where treatment is rounded off with the topical medication as a precaution against a possible recurrence. Whether to use the medication, and for how long, is decided after an examination.
What to Keep in Mind
The figures cited in this article are values reported in individual studies, and actual results can vary with the shape of the lesion and from person to person. This article is a general explanation and does not replace an individual diagnosis.
References
- Gilmore A, Kelsberg G, Safranek S. What's the best treatment for pyogenic granuloma? J Fam Pract. 2010;59(1):40-41.
- Pyogenic granuloma – the quest for optimum treatment: audit of treatment of 408 cases. J Plast Reconstr Aesthet Surg. 2007;60(9):1030-1035.
- Comparison of cryotherapy and curettage for the treatment of pyogenic granuloma: a randomized trial. Br J Dermatol. 2006.
Frequently Asked Questions
- Where does pyogenic granuloma commonly develop?
- It is a benign vascular tumor that commonly develops on the skin and mucous membranes, and in dermatology clinics we mainly see it near the fingernails or toenails and on the lips. It also commonly develops on mucous membranes such as the gums.
- What causes pyogenic granuloma?
- It mainly develops when a minor wound does not heal and keeps being irritated, when female hormones play a part, as with pregnancy, puberty or taking oral contraceptives, and when it is brought on by medications such as anticancer drugs. With causes like these, inflammation continues and blood vessels proliferate excessively, and the lesion forms.
- It keeps bleeding. Is it all right to touch it?
- Pyogenic granuloma bleeds easily with even minor irritation and tends to grow little by little the more it is touched. It is better not to keep touching it. The treatment method is decided after the shape of the lesion has been checked.
- Which is better, having it cut out surgically or another treatment?
- Surgical excision is regarded as the standard treatment, and in a study that analyzed 408 cases it was reported to be the method with the fewest recurrences. However, another study, in pediatric patients, reportedly found subtle scarring in more than half of cases, so less invasive treatments are often looked at first to reduce the burden of scarring. Which method is suitable depends on the shape of the lesion.
- Is one session of vascular laser or cryotherapy enough?
- Sometimes one session is enough, but it is not uncommon to need several. The drawback of these methods is that, in exchange for being less invasive, the number of sessions can go up. There are also cases where the response is not sufficient even after several rounds of vascular laser.
- When can the lesion be tied off with thread?
- It is considered when the lesion is narrow at the base and bulges outward, a shape that can be tied off with thread. When it is tied off with medical-grade thread to restrict the blood flow, there are cases where it drops off within a day or two after a single treatment. For shapes that cannot be tied off, other treatments are combined.
- Can I tie it off with thread at home?
- No, please do not. Tying it off yourself with ordinary thread can lead to infection or excessive bleeding. Whether it is a shape that can be tied off at all needs to be checked in clinic first.
- Can it come back after treatment?
- It can come back. Recurrence is reported even with treatments that remove the lesion directly, such as surgical excision and electrocautery. As a precaution against recurrence, a topical medication called timolol is sometimes used alongside after treatment.