Treatment of Pyogenic Granuloma in Children With the Flashlamp-pumped Pulsed Dye Laser

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Treatment of Pyogenic Granuloma in Children With the

Flashlamp-pumped Pulsed Dye Laser

Yong-Kwang Tay, MD; William L. Weston, MD; and Joseph G. Morelli, MD

ABSTRACT. Objective. Pyogenic granuloma is a com-mon, acquired, vascular tumor of the skin in children, often ulcerates or bleeds, and is commonly localized to the face. The treatment of choice has been surgical re-moval, either by excision or shave, followed by electro-cautery. The site, young age of the patient, and the in-herent nature of surgical removal or electrocautery often make this procedure a traumatic experience. Also, surgi-cal treatment usually leads to permanent scarring. Owing to the pulsed dye laser’s ability to cause selective destruc-tion of superficial capillary-sized cutaneous blood ves-sels, its ease of operation, and its lack of scarring, we evaluated its use in the treatment of pyogenic granuloma in children.

Methods. Twenty-two children with solitary pyo-genic granulomas were treated with a vascular-specific (585 nm), pulsed (450 microseconds) dye laser using a 5-mm spot size with a laser energy of 6 to 7 J/cm2without

anesthesia. Retreatments were administered every 2 weeks if necessary until the lesion cleared. Posttreatment care consisted of twice-a-day application of bacitracin ointment.

Results. In 20 patients (91%), laser treatment was suc-cessful. Five patients (25%) required one treatment for resolution, eight patients (40%) required two treatments, and six patients (30%) required three treatments for clear-ing. One patient required six treatments before the lesion resolved. There was no correlation with the duration, or site of the lesion, with respect to the number of laser treatments required. Lesions in all 20 children healed without scarring and with excellent cosmetic results. In two patients (9%), laser treatment failed in that there was no response to the initial laser treatment on follow-up 2 weeks later. Both had large pyogenic granulomas (1 cm and .5 cm in diameter, respectively) which were elevated over .5 cm above the surface of the skin. These lesions were surgically removed. None of the patients had a recurrence during the follow-up period of 6 months to 3 years.

Conclusion. Pulsed dye lasers are effective and safe for the treatment of small pyogenic granulomas in chil-dren and should be considered a treatment option. Pediatrics 1997;99:368 –370; pyogenic granuloma, pulsed dye laser.

Pyogenic granuloma is a benign, acquired, vascu-lar tumor of the skin and mucous membranes in

infancy and childhood. Solitary pyogenic granulo-mas are common and represent .5% of all skin nod-ules in children.1 It usually presents as a rapidly-growing, firm, bright-red papule that is prone to bleeding or ulceration, and is most commonly local-ized to the head and neck. Traditional treatment methods have included surgical excision with linear closure, shave excision followed by electrodessica-tion to the base, or destrucelectrodessica-tion by electrocautery alone. Although these modalities have been used successfully, local recurrence is not uncommon, and the site, young age of the patients, and the inherent traumatic nature of these methods often pose a ther-apeutic challenge. We report on 22 children with pyogenic granuloma treated with the pulsed dye laser.

METHODS

Twenty-two children with solitary pyogenic granulomas were seen at the University Hospital over a 3-year period. After a clinical diagnosis had been made, the condition was explained to the parents and the various treatment options were discussed. If the parents were agreeable to laser treatment, the entire lesion was treated with a pulsed (450 microseconds) dye (585 nm) laser using a 5-mm spot size (Candela SPTL-1, Candela Laser Corp, Wayland, MA, or PhotoGenica V, Cynosure Incorp, Bedford, MA).

All treatments were performed with a laser energy of 6 to 7 J/cm2and without anesthesia or sedation. Although the treatment

is somewhat painful, it requires less than 10 seconds to deliver the minimal number of pulses necessary to treat a pyogenic granu-loma. The individual pulses were minimally overlapped. On fol-low-up, 2 weeks later, if the initial lesion had become smaller, the lesion was treated again. Retreatments were administered every 2 weeks until the lesion cleared. Failure was defined as no response to laser treatment during the second visit, with the lesion either remaining the same size or becoming larger. If this occurred, shave excision followed by electrodessication to the base was performed. Posttreatment care consisted of twice-a-day applica-tion of bacitracin ointment.

RESULTS

The mean age of the 22 patients was 3.4 years (range, 6 months to 16 years). The majority of pyo-genic granulomas (13 patients [59%]) appeared within the first 5 years of life. In six children (26%), the lesions appeared between 6 and 12 months of life. The frequency decreased with age, with only three patients between ages 9 to 16 years.

There were 13 males and 9 females, giving a ratio of 1.4:1. The average duration that the lesions were present before treatment was 2 months (range, 1 week to 6 months). Most of the lesions were small, with an average diameter of 4 mm (range, 2 mm to 1 cm). In 18 patients (82%) the lesions were situated on the face, and in two patients (9%) they were situated

From the Department of Dermatology, University of Colorado Health Sciences Center, Denver, Colorado.

Received for publication Jan 16, l996; accepted Apr 17, l996.

Reprint requests to (J.G.M.) Department of Dermatology, Box B153, University of Colorado Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262.

PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Acad-emy of Pediatrics.

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on the neck. In one patient, the lesion was situated on the right fourth finger, and in the remaining patient, it was situated on the right shoulder overlying a port-wine stain. Of the facial lesions, the cheeks were most commonly affected, (eight patients, 44.4%), fol-lowed by the temporal area (four patients, 22.2%), and the forehead (three patients, 16.7%). In the re-maining three patients, the lesions were situated be-low the eyes in two children, and on the be-lower eyelid in one child.

The majority of patients (91%) had no history of preexistent trauma or skin condition. One patient had a history of trauma before the growth of the lesion on the left cheek, and in another patient the pyogenic granuloma was situated on the right shoul-der over an extensive port-wine stain extending from the right side of the neck to the right-upper portion of the chest. Before treatment, bleeding occurred in eight patients (36%) and ulceration in four patients (18%).

In 20 patients (91%), laser treatment resulted in complete clearance of the pyogenic granuloma. (See the Table). None of these lesions were elevated more than 2 or 3 mm above the skin. In five patients (25%), the pyogenic granuloma completely resolved after one laser treatment. In eight patients (40%), the le-sion resolved after two laser treatments. Six patients (30%) required three laser treatments for resolution. One patient who had a 5-mm-diameter pyogenic granuloma over the left temple required six laser treatments with a total of 24 pulses before the lesion resolved. As the pyogenic granuloma became smaller with successive treatments, the number of pulses required at each treatment session decreased correspondingly. There was no correlation with the duration or site of the lesion with respect to the number of laser treatments required. All lesions healed without scarring and with excellent cosmetic results.

In two patients (9%), laser treatment failed. Both children had large pyogenic granulomas. One child had a 1-cm-diameter pedunculated lesion over the left temple, and the other had a .5-cm-diameter le-sion over the left cheek. Both lele-sions were elevated over .5 cm above the skin. In these patients, the pyogenic granuloma was removed by shave excision with electrodesiccation to the base. No recurrence was documented during the follow-up period rang-ing from 6 months to 3 years. The Figure shows a lesion before and after treatment.

DISCUSSION

Most pyogenic granulomas occur within the first 5 years of life, and males are more frequently affected.

In a series of 178 cases reported by Patrice et al,242% occurred within the first 5 years of life, and the male-female ratio was 1.5:1. We had similar findings. Most pyogenic granulomas are small, less than 5 mm in diameter. The mean diameter was 4 mm in our series, and 6.5 mm in the Patrice series.2Bleeding and ulceration are common, and occurred in more than half of our cases.

On histology, pyogenic granuloma exhibits a lob-ular arrangement of capillaries separated by a fibro-myxoid stroma.3 The etiology remains unknown. Postulated predisposing factors have included: trauma, hormonal influences such as pregnancy, bac-terial and viral infections, microscopic arteriovenous anastomoses, and angiogenic growth factors.4 Al-though trauma has been assumed to play a major role in the pathogenesis of pyogenic granuloma,5 only one of our patients had a history of prior injury. In the Patrice series,2only 7% had a history of trauma preceding the onset of the lesion. Pyogenic granulo-mas frequently occur within port-wine stains and have a predilection for the head and neck, suggesting that unknown angiogenic stimuli may be triggered in dense vascular beds.6 Pyogenic granuloma can best be considered a disorder of angiogenesis of un-known etiology.2

Effective modes of therapy have included simple excision, electrodessication, curettage, and chemical cauterization with silver nitrate. Both the carbon di-oxide and argon lasers have been used successfully

TABLE. Twenty Patients With Solitary Pyogenic Granulomas Treated Successfully With Pulsed Dye Laser

No. of Laser Treatments to

Resolution

No. of Patients (%) No. of Pulses Required for Clearing (Mean)

1 5 (25) 1–5 (2.6)

2 8 (40) 6–9 (7.8)

3 6 (30) 4–13 (9.2)

6 1 (5) 24

Figure. A, 4-mm-diameter pyogenic granuloma below the left eye of a 2-year-old boy. B, 3 months later, complete resolution of the lesion after one session of pulsed dye laser.

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to treat pyogenic granulomas.7,8Recently, Goldberg and Sciales9treated three children with solitary pyo-genic granulomas with the flashlamp-pumped pulsed dye laser with excellent cosmetic results. Some authorities10 have recommended the use of a glass slide to compress the lesion and then irradiate the lesion using fluences of between 7.5 and 8 J/cm2. The glass slide is then removed and the lesion irra-diated with 7 to 8 J/cm2. This reduces bleeding and enables deeper penetration into the dermis. In our series of patients, we did not use a glass slide, but simply irradiated the entire lesion.

The advantage of the pulsed dye laser over other techniques is its ease of operation, rapidity of treat-ment, and inherent low morbidity, making it ideal for use in children. Another advantage of the pulsed dye laser is the absence of scar formation, owing to its ability to cause selective destruction of superficial blood vessels while leaving surrounding tissue un-affected, in contrast to the carbon dioxide and argon lasers. The disadvantage of the pulsed dye laser is the need for repeated treatments and the possibility that the treatment may not work, especially for larger lesions, necessitating surgical removal. Secondary to the minimal depth of penetration of the pulsed dye laser, pyogenic granulomas which are pedunculated or raised over .5 cm above the skin surface are much less likely to respond to treatment. At present, there is no way to predict which patients will respond to a single treatment and which patients will require

multiple treatments. In our series, one-quarter of our patients required a single treatment for clearance, and 40% required two treatments.

In conclusion, we believe that pulsed dye lasers are safe and effective for the treatment of small, minimally elevated pyogenic granulomas in children and should be considered a treatment option.

REFERENCES

1. Grimalt R, Caputo R. Symmetric pyogenic granuloma. J Am Acad

Der-matol. 1993;29:652

2. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol. 1991;8:267–276

3. Mills SE, Cooper PH, Fechner RE. Lobular capillary hemangioma: the underlying lesion of pyogenic granuloma. Am J Surg Pathol. 1980;4: 471– 479

4. Mooney MA, Janniger CK. Pyogenic granuloma. Cutis. 1995;55:133–136 5. Kerr DA. Granuloma Pyogenicum. Oral Surg Oral Med Oral Pathol.

1951;4:158 –176

6. Swerlick RA, Cooper PH. Pyogenic granuloma (lobular capillary he-mangioma) within port-wine stains. J Am Acad Dermatol. 1983;8:627– 630 7. Modica LA. Pyogenic granuloma of the tongue treated by carbon

diox-ide laser. J Am Geriatr Soc. 1988;36:1036 –1038

8. Apfelberg DB, Maser MR, Lash H, Flores J. Expanded role of the argon laser in plastic surgery. J Dermatol Surg Oncol. l983;9:145–151 9. Goldberg DJ, Sciales CW. Pyogenic granuloma in children. Treatment

with the flashlamp-pumped pulsed dye laser. J Dermatol Surg Oncol. 1991;17:960 –962

10. Tan OT, Kurban AK. Noncongenital benign cutaneous vascular lesions: pulsed dye laser treatment. In: Tan OT, ed. Management and treatment of

benign cutaneous vascular lesions. Philadelphia, PA: Lea and Febiger;

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DOI: 10.1542/peds.99.3.368

1997;99;368

Pediatrics

Yong-Kwang Tay, William L. Weston and Joseph G. Morelli

Pulsed Dye Laser

Treatment of Pyogenic Granuloma in Children With the Flashlamp-pumped

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DOI: 10.1542/peds.99.3.368

1997;99;368

Pediatrics

Yong-Kwang Tay, William L. Weston and Joseph G. Morelli

Pulsed Dye Laser

Treatment of Pyogenic Granuloma in Children With the Flashlamp-pumped

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