Multiple disseminated pyogenic granuloma post-oil burning: A review of literature

Fariba Iraji; Minoo Jelvan; Zakiye Ganjei; Parvin Rajabi

doi:10.4103/ijd.IJD_371_18

Publication of IADVL, WB
Official organ of AADV

Indexed with Science Citation Index (E) , Web of Science and PubMed

IJD^®

Users online: 2444

Archives

Online Early

Coming Soon

Guidelines

Subscriptions

e-Alerts

E-IJD® - CASE REPORT

Year : 2022 | Volume : 67 | Issue : 6 | Page : 836

Multiple disseminated pyogenic granuloma post-oil burning: A review of literature

Fariba Iraji¹, Minoo Jelvan¹, Zakiye Ganjei¹, Parvin Rajabi²
¹ Department of Dermatology, Medical School, Isfahan University of Medical Sciences, Al-Zahra Hospital, Isfahan, Iran
² Department of Pathology, Medical School, Isfahan University of Medical Sciences, Al-Zahra Hospital, Isfahan, Iran

Date of Web Publication

23-Feb-2023

Correspondence Address:
Minoo Jelvan
Department of Dermatology, Medical School, Isfahan University of Medical Sciences, Al-Zahra Hospital, Isfahan
Iran

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ijd.IJD_371_18

Abstract

Pyogenic granuloma (PG) is a common acquired vascular tumor and may appear mostly as a solitary papulonodular lesion on the face, trunk, and extremities. Although the etiology of PG is unclear, trauma, infections, and hormones may play a role. Multiple disseminated PGs are a very rare form and mostly are seen after traumas such as burn. We presented a patient with multiple PGs secondary to oil burning. There has been no report of PG caused by scald burn due to oil before. We also reviewed the literature in English and found 24 other cases of disseminated PG that most of them developed post-boiling milk.

Keywords: Disseminated, lobular capillary hemangioma, oil burning, pyogenic granuloma

How to cite this article:
Iraji F, Jelvan M, Ganjei Z, Rajabi P. Multiple disseminated pyogenic granuloma post-oil burning: A review of literature. Indian J Dermatol 2022;67:836

How to cite this URL:
Iraji F, Jelvan M, Ganjei Z, Rajabi P. Multiple disseminated pyogenic granuloma post-oil burning: A review of literature. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:836. Available from: https://www.e-ijd.org/text.asp?2022/67/6/836/370294

Introduction

Pyogenic granuloma (PG), or lobular capillary hemangioma, is a common acquired proliferative vascular lesion of the skin and mucous membrane that may appear throughout childhood and adulthood. They occur most often on the face and distal extremities as a solitary, red nodule. PG has a pliable surface and bleed easily.^[1],[2],[3] While etiology of PG is unclear, trauma, infections, female sex hormones, viral oncogenes, microscopic arteriovenous anastomosing, and growth factors are considered as etiologic factors.^[4]

There have been several reports of solitary PG after trauma and multiple disseminated PGs are a very rare form of PG and generally seen after traumas such as burns.

We presented a patient with multiple PGs developed after third-degree scald burn due to oil, and this is the first report of disseminated PG post-oil burning. We also reviewed the literature and found 24 other cases that mostly caused by milk burning.^{[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17]}

Case Report

A 30-year-old woman was referred to our department (Al Zahra Hospital; Referral Center for Treatment of Skin Diseases). The patient had 60% body surface third-degree burn due to oil 4 weeks before.

She was treated using daily dressing with silver sulfadiazine and intravenous antibiotic in a burn care center (Imam Musa Kazim hospital), and the burned skin in her thigh was successfully repaired with full-thickness skin graft from the left forearm origin. During this period, 24 days after the burn injury, multiple papillomatoses and nodular lesions appeared periphery of the burn site and also around the donor site on her forearm [Figure 1]. The lesions grew and bled easily.

Figure 1: The appearance of multiple pyogenic granulomas on patient's forearm, 4 weeks after burn injury

Click here to view

Laboratory investigation including complete blood count, liver, and renal function tests was within normal range. HIV and human T-lymphotropic virus serology were negative. Blood and fresh tissue cultures for Bartonella spp. were negative.

Histopathology examination showed hyperkeratosis, dermal edema, intense inflammatory cell infiltration (mostly lymphocytes and plasma cells), and bloody vessel proliferation [Figure 2].

Figure 2: (a) Histopathologic examination showed small capillaries with variable luminal diameters in an edematous stroma with scattered inflammatory cells; Hematoxylin and eosin, original magnification: (a) ×40, (b) ×100

Click here to view

The pathological features of this biopsy consisted with the clinical diagnosis of PG. Besides conservative treatment such as daily dressing and antibiotic, the excision of the lesions followed by electrosurgery of the base under local anesthesia was planned for her treatment and performed in the primary local facility. There was no evidence of recurrence 6 months later [Figure 3].

Figure 3: Postoperative, 6 months later, view of the patient's forearm

Click here to view

Discussion

PG is a common acquired vascular tumor that is more common in the pediatric age group. The lesions present as rapidly growing papulonodules that are extremely friable, frequently ulcerate, and may bleed profusely with minor trauma. They appear mostly on the face, trunk, and distal extremities. While the etiology of PG remains unclear, the possible predisposing factors that affect the pathogenesis include trauma, infections, elevated female sex hormones level, viral oncogenesis, microscopic arteries venous anastomosis, and growth factors.^{[1],[2],[3],[4]}

PG of different sizes occurs often as single lesions and multiple disseminated lesions are a rare form of PG, and in general, burns and widespread traumas may play a role in this form of PG. PG develops over the burned area between 1 and 4 weeks following burns and may be infected with bacteria and fungi.

As in other cases in the literature in English, there were 24 cases of disseminated PG following burn from 1978 to 2018.^{[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17]} The cases occurred approximately between 1 and 4 weeks following burning mostly secondary to milk (nine cases), eight cases of scald burn, one case provoked by hot water, and four thermal burns or flames and two cases are not mentioned. Surprisingly, in our patient, the etiology was oil. In a majority of cases, the lesions developed following the second-degree burn [Table 1].

Table 1: Reported pyogenic granuloma post burns

Click here to view

Differential diagnosis includes amelanotic melanoma, squamous cell carcinoma, angiosarcoma, Kaposi sarcoma, hemangioma, bacillary angiomatosis, metastatic visceral malignancies, and granulation tissue.^[14] These entities were ruled out both by clinical findings, histopathological studies, and/or microbiological cultures.

Conservative treatment including wound management and antibiotic could be chosen first, especially when large PG is on the face or other important areas of the body. As PG can involve the reticular dermis, pulse dye lasers, cauterization, and shave excision may not be able to reach the entire PG, and these methods of treatment have a recurrence rate of 43.5%.^[18]

In our patient, the lesions were surgically excised and followed by electrosurgery of the base, and no occurrence was observed during 6 months.

On a basic scale level, we think that the burn etiology and not the burn injury itself is important because all similar cases have the same etiology that may not be a coincidence, and milk proteins might cause the development of PG; to the best of our knowledge, the most probable etiology is not a trauma or infection itself, but an idiosyncratic response to previous insults with the accompanying release of various proliferative and growth factors such as endothelial growth factor, fibroblast growth factor, and interleukin 1 B may play a role.^[10],[19]

Oil burning is reported in our case as a cause of disseminated PG for the first time so more research focusing on the etiology is needed, and the reasons why every trauma could not cause PG and why the same patient could not develop PG at later trauma are unclear.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): A clinicopathologic study of 178 cases. Pediatr Dermatol 1991;8:267-76.
2.	Kapadia SB, Heffner DK. Pitfalls in the histopathologic diagnosis of pyogenic granuloma. Eur Arch Otorhinolaryngol 1992;249:195-200.
3.	Kirschner RE, Low DW. Treatment of pyogenic granuloma by shave excision and laser photocoagulation. Plast Reconstr Surg 1999;104:1346-9.
4.	Ceyhan AM, Basak PY, Akkaya VB, Yildirim M, Kapucuoglu N. A case of multiple, eruptive pyogenic granuloma developed on a region of the burned skin: Can erythromycin be a treatment option? J Burn Care Res 2007;28:754-7.
5.	de Kaminsky AR, Otero AC, Kaminsky CA, Shaw M, Formentini E, Abulafia J. Multiple disseminated pyogenic granuloma. Br J Dermatol 1978;98:461-4.
6.	Momeni AZ, Enshaieh S, Sodifi M, Aminjawaheri M. Multiple giant disseminated pyogenic granuloma in three patients burned by boiling milk. Int J Dermatol 1995;34:707-10.
7.	Ceyhan M, Erdem G, Kotiloğlu E, Kale G, Talim B, Kanra G, et al. Pyogenic granuloma with multiple dissemination in a burn lesion. Pediatr Dermatol 1997;14:213-5.
8.	Liao WJ, Fan PS, Fu M, Gao TW, Liu YF, Ikeda S, et al. Clinicopathological and ultrastructural study of multiple lobular capillary hemangioma after scalding. Dermatology 2006;213:34-6.
9.	Aliağaoğlu C, Bakan V, Atasoy M, Toker S. Pyogenic granuloma with multiple and satellite involvement after a burn in a 5-year-old child. J Dermatol 2006;33:150-2.
10.	Bozkurt M, Külahçi Y, Zor F, Aşkar I. Multiple giant disseminated pyogenic granuloma in a burn lesion. J Burn Care Res 2006;27:247-9.
11.	Diallo M, Niang SO, Kane A, Dieng M, Ndiaye B. Pyogenic granulomas with multiple satellites spontaneously resolved. Nouv Dermatol 2006;25:701-3.
12.	Ozbayoğlu AC, Aksungur E, Senem A. Pyogenic granuloma developed in a healed flame burn area and review of the literature: Case report. Turk Plast Surg 2011;19:27-9.
13.	Shirol SS, Nimbaragi G, Choukimath SM, Yenni VV. Lobular capillary hemangioma in a post-burn scar. Eur J Plast Surg 2013;36:323-6.
14.	Durgun M, Selçuk CT, Ozalp B, Aydinol M, Alabalik U. Multiple disseminated pyogenic granuloma after second degree scald burn: A rare two case. Int J Burns Trauma 2013;3:125-9.
15.	Zhao H, Zhao H, Zhang C, Fu X. Multiple pyogenic granulomas after burns: Response to conservative treatment in five children. Pediatr Dermatol 2015;32:e175-6.
16.	Dastgheib L, Maghami Z, Aslani FS. Infantile multiple large pyogenic granuloma on burned skin. Case report and review of literature. An Bras Dermatol 2016;91:212-4.
17.	Xu Y, Li H, Wang ZX, Yang S. Multiple eruptive pyogenic granulomas occurring in a region of scalded skin. Pediatr Dermatol 2016;33:e27-8.
18.	Zhao H, Huang S, Fu X. Should pyogenic granulomas following burns be excised? Burns 2015;41:431-6.
19.	Yuan K, Wing LY, Lin MT. Pathogenetic roles of angiogenic factors in pyogenic granulomas in pregnancy are modulated by female sex hormones. J Periodontol 2002;73:701-8.