Rapidly Growing Finger Lesion

Correct answer: C. Pyogenic Granuloma

Our patient presents with typical clinical features of pyogenic granuloma (PG), which is also known as lobular capillary hemangioma. This starts as a small, red papule that grows rapidly over weeks to months. Pyogenic granuloma can develop in the skin and mucosa surfaces. The surface of his lesion was friable, which is also a characteristic of PG. It is also a mostly solitary lesion but there are some that develop in disseminated fashion. Our patient’s lesion was solitary and was in the upper extremity on the skin over the middle phalanx of his left ring finger; the upper extremity being a common site of occurrence of PG in adults.

Although the patient presented with the clinical features associated with PG, he did not have any of the common triggers for PG. Among the differential diagnoses were basal cell carcinoma, cherry angioma, pyogenic granuloma, Kaposi sarcoma, the common wart, and others, all of which were ruled out based on their characteristics (Table). Several differentials could be life threatening, such as basal cell carcinoma, squamous cell carcinoma, and amelanotic melanoma, which is often misdiagnosed as PG. Additionally, port wine stain may be associates with PG, albeit a rare association.

Table. Selected differential diagnosis with key differentiating characteristics.

Treatment and management. There are different treatment modalities used in the management of PG, including surgical treatments (full thickness excision, shave excision, curettage, laser therapy, cryotherapy), topical and intralesional therapies (steroids, topical dapsone), and the combination of surgical and nonsurgical therapies.¹

Factors that might influence the choice of treatment includes the size and location of the lesion, the risk of reoccurrence and scarring, and patient age. In addition, provoking factors such as trauma should be prevented as much as possible, any foreign body should be removed, and medication should be discontinued if feasible.¹

Due to the location and pedunculated form of the lesion in our patient, treatment included excisional biopsy with local anesthesia after informed consent was obtained. Cauterization with silver nitrate to minimize and control the bleeding was also applied. The procedure was tolerated well by the patient with minimal bleeding.

Outcome and follow-up. The patient was advised to follow up in 1 week for re-evaluation of the excision site, but the patient did not return for an in-person visit. A phone call was made to the patient, and he expressed satisfaction with the procedure and stated no reoccurrence.

Discussion. Pyogenic granulomas are common benign vascular tumors of the skin or mucous membranes.^2,3 These tumors are also known as lobular capillary hemangiomas. While the etiology is not fully understood, some result from trauma to the skin, use of certain medications (including systemic retinoids, chemotherapy agents, and HIV protease inhibitors), or pregnancy. These lesions grow rapidly over weeks to months up to 1 centimeter and bleed profusely, as seen in this patient. They are typically asymptomatic and occur most frequently in children and young adults. On presentation, a solitary red, firm papule is noted. They occur most commonly on the head and neck in children and on the trunk and extremities in adults. Pyogenic granulomas can be sessile or pedunculated and may become ulcerated and crusted. The diagnosis is clinical, but a biopsy may be obtained for confirmation. Management entails discontinuing offending medications if applicable, and removal via excision, curettage and electrodessication, laser, or cryotherapy. Those that arise during pregnancy may resolve spontaneously after delivery. Recurrence rates following treatment range from 0% to 15%, depending on treatment modality and location of lesion.^2,3

Basal cell carcinoma is the most common form of skin cancer. They typically present on sun-damaged skin of older adults, with various morphologies ranging from pearly and nodular to superficial thin plaques or infiltrative depressed ulcerations. Patients may complain of pruritus and bleeding, or no symptoms at all.⁴ Basal cell carcinomas do not typically have such pronounced vascularity as PG.

Cherry angiomas are the most common form of benign cutaneous vascular proliferation. They present as domed, ruby red papules. They are typically smaller than 3.5 mm, but range from 1 mm to 5 mm. There is a propensity to occur in clusters of lesions and to localize to the trunk or proximal extremities, unlike in our patient. They may also bleed with trauma. These lesions become more common with aging, with most cases occurring after age 75 years. They are also associated with pregnancy and genetic mutations.⁵

Kaposi sarcoma is a soft tissue tumor caused by human herpesvirus (HHV-8) and is most associated with immunosuppressed or immunodeficient patients, such as those with AIDS. These purplish lesions progress from patch to plaque to nodules of mucocutaneous surfaces and may present with lymph node involvement. The classic Mediterranean form commonly presents on lower extremities of older men, while the endemic African form more often affects children.⁶

Common warts are benign lesions caused by human papillomavirus infection, which may present as verruca or papilloma. These are common among school-aged children, those with pre-existing dermatitis, and the immunocompromised. Transmission occurs by direct skin contact or autoinoculation. Warts do not typically present with predominant vascularity.⁷

In conclusion, physicians should be aware that malignant tumors can mimic PG, and therefore, confirmation of the diagnosis is necessary through an excisional biopsy and histology examination. Health care practitioners should not take lightly any lesion on the skin surface of a patient when an accurate diagnosis has not been confirmed. This will also help to tailor the appropriate and effective treatment for the patient.

References:

1. Lawley LP, Levy ML, Corona R. Pyogenic granuloma (lobular capillary hemangioma). UpToDate. Updated May 29, 2024. Accessed October 2023. https://www.uptodate.com/contents/pyogenic-granuloma-lobular-capillary-hemangioma
2. Barankin B, Freiman A. Derm Notes: Dermatology Clinical Pocket Guide. F.A. Davis Company; 2006.
3. Usatine RP, Krejci-Manwaring J. Textbook of Family Medicine. 8th ed. Elsevier; 2012.
4. Cameron MC, Lee E, Hibler BP, et al. Basal cell carcinoma: epidemiology; pathophysiology; clinical and histological subtypes; and disease associations. J Am Acad Dermatol. 2019;80(2):303-317. doi:10.1016/j.jaad.2018.03.060.
5. Qadeer HA, Singal A, Patel BC. Cherry Hemangioma. StatPearls Publishing; 2023. Accessed May 2023. https://www.ncbi.nlm.nih.gov/books/NBK563207/
6. Bishop BN, Lynch DT. Kaposi Sarcoma. StatPearls Publishing; 2023. Accessed May 2023. https://www.ncbi.nlm.nih.gov/books/NBK534839/
7. Sterling JC, Gibbs S, Hussain H, et al. British Association of Dermatologists’ guidelines for management of cutaneous warts 2014. BJD. 2014;171(4):696-712. doi:10.1111/bjd.13310.

AUTHORS:
Afolake Mobolaji, MD, MPH, FAAFP • Nwamaka Dike, MD • Folashade Omole, MD, FAAFP

AFFILIATION:
Department of Family Medicine, Morehouse School of Medicine, Atlanta, GA

CITATION:
Mobolaji A, Dike N, Omole F. Rapidly growing finger lesion. Consultant. Published online July 19, 2024. doi:10.25270/conn.2024.07.000005.

Received January 9, 2024. Accepted April 24, 2024.

DISCLOSURES:
The authors report no relevant financial relationships.

ACKNOWLEDGEMENTS:
None.

CORRESPONDENCE:
Afolake Mobolaji, MD, MPH, FAAFP, 720 Westview Drive SW, Atlanta, GA, 30310 (amobolaji@msm.edu)

© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of Consultant360 or HMP Global, their employees, and affiliates.