A four-year-old girl presented with an asymptomatic lesion over the right cheek of two months duration. History of precedent trauma and bleeding on manipulation was present. There was no drug intake or systemic complaints. Cutaneous examination showed a solitary, soft, non-tender, vascular papule with surrounding hemorrhagic crust over right cheek (Fig. 1). Systemic examination was normal. A clinical diagnosis of pyogenic granuloma was confirmed by excisional biopsy.

Fig.1 Multiple deep seated ulcers with undermined edge on the dorsum of the right foot (A), and left retro auricular area (B); Highly reactive mantoux test(C).

The term pyogenic granuloma (PG) is a misnomer, as it is neither infectious nor granulomatous. It is a reactive vascular nodule usually occurring after injury or irritation. PG is commoner in children and young adults, with no sexual predilection. PG may be associated with drugs like systemic retinoids, indinavir, etc.

Clinically, PG presents as a solitary, painless, red, brownish-red or bluish black papule/nodule. It is partially compressible without pulsation. Common sites affected are fingers, feet, lips, head, upper trunk, oral mucosa and perianal area. Spontaneous disappearance is rare. Histologically, a well circumscribed proliferation of small capillaries in a lobular pattern is seen. Differential diagnoses are hemangiomas, glomus tumors, warts and molluscum contagiosum. Hemangiomas are scarlet-red, non-tender, compressible, dome shaped papules/nodules present at birth/early infancy characterised by early rapid proliferation and spontaneous involution by 1-9 years of age. Glomus tumors are multiple, congenital, red/blue, less compressible, painful/painless papules coalescing to form plaques over any part of the body. Warts are multiple, asymptomatic, verrucous papules anywhere over the body; when inflamed, they may resemble PG. Molluscum contagiosa are multiple, pearly/skin coloured umbilicated papules; when infected/irritated they may simulate PG. However, all these conditions may be differentiated from PG by histopathology. Complications of PG include ulceration, profuse bleeding, development of satellite lesions or disseminated, eruptive occurrence. Treatment includes curettage with cauterization of the base, surgical excision, sclerotherapy, cryosurgery and pulsed dye laser.