BJD
British Journal of Dermatology
CASE REPORT
A pyogenic granuloma treated with topical timolol M. Malik and R. Murphy Department of Dermatology, Queens Medical Centre, Nottingham University Hospital, Nottingham NG7 2UH, U.K.
Summary Correspondence Moona Malik. E-mail: [email protected]
Accepted for publication 6 May 2014
Funding sources None.
Conflicts of interest
Pyogenic granulomas are benign vascular tumours usually surgically treated by excision or curettage. The only topical therapy reported to date is imiquimod 5% cream but it produces a marked inflammatory response with discomfort generally worse than simple surgical excision or curettage. Here we report the use of timolol 05% ophthalmic gel used successfully to treat a teenager with a clinically classical pyogenic granuloma on the finger. There were no reported adverse effects and the lesion completely resolved. It has not recurred after 7 months. Timolol may be an effective and preferable alternative treatment to surgery for a classical small pyogenic granuloma, particularly in children and young people.
None declared. DOI 10.1111/bjd.13116
What’s already known about this topic?
•
Beta-blockers, including topical timolol and propranolol, are effectively used in the treatment of infantile haemangiomas. The only reported medical therapy for pyogenic granulomas is imiquimod.
What does this study add?
•
This report acts as a proof of the concept that topical timolol may be an alternative therapeutic option for classical pyogenic granuloma, particularly in children and young people.
Pyogenic granulomas are lobular capillary haemangiomas most commonly treated surgically by curettage or excision. Surgery has the advantage of providing histological confirmation of the diagnosis, but is an invasive procedure and may not be necessary in clinically typical cases. Beta-blockers, both systemic and topical, have been used effectively in the treatment of infantile haemangiomas, generally without prior histological confirmation of the diagnosis.1 While the majority of the evidence is with systemic agents such as propranolol, there is a growing literature for the use of topical agents such as timolol for small superficial lesions.2 Infantile haemangiomas and pyogenic granulomas have different pathogenesis and behaviour. However, both are benign proliferative vascular neoplasms and hence we tried timolol 05% gel for the treatment of a clinically classical pyogenic granuloma occurring on the finger of a child. There was complete resolution of the lesion after 3 weeks of twicedaily topical treatment with topical timolol 05% gel. Topical timolol might be a useful option for clinicians when treating classical pyogenic granulomas particularly in children and young people.
Case report
© 2014 British Association of Dermatologists
British Journal of Dermatology (2014) 171, pp1537–1538
A 14-year-old child presented with a 2-month history of a new vascular lesion on the index finger of the right hand. This bled easily and was increasing in size. Examination showed a 1-cm vascular nodule on the medial aspect of the distal phalanx of the right index finger, clinically consistent with a pyogenic granuloma (Fig. 1). This was treated with timolol 05% ophthalmic gel, twice a day, for 2 weeks. At follow-up, a 90% improvement was noted, and another week of treatment advised. The lesion completely resolved and had not recurred at 7 months (Fig. 2).
Discussion Pyogenic granuloma is a benign vascular proliferation that commonly affects the fingers, hands, forearms and face. It is also called a lobular capillary haemangioma owing to its histological features. Spontaneous resolution is rare. Bleeding and secondary infection are common complications. A differential 1537
1538 Pyogenic granuloma treated with topical timolol, M. Malik and R. Murphy
Fig 1. Pyogenic granuloma at presentation.
there have been several case reports, case series, prospective and retrospective studies, and a randomized controlled trial (RCT) supporting its use.2,5 To the best of our knowledge, only one case has been reported so far about the use of topical timolol for a pyogenic granuloma.6 Topical timolol was used for a month on the cheek of a 5-month-old infant with no recurrence of the pyogenic granuloma after 8 months. We are aware that the limitations of this case are the lack of histology, and would advocate the need for surgical treatment for histological confirmation if there was no response to therapy after 3 weeks of twice-daily use. Also, it would be particularly important to select only clinically typical cases. Without further evidence from case series or RCTs, we do not advocate its routine use. However, with the fear of surgery and low risk of melanoma in children, this may prove to be a useful therapeutic option. A case series with more information about treatment regimen and long-term recurrence would be needed before it could be recommended as an alternative to surgery. However, it might prove to be a useful alternative to surgery in children who present with classical, small, uncomplicated pyogenic granulomas.
References
Fig 2. Resolved pyogenic granuloma after topical timolol gel.
diagnosis includes amelanotic melanoma but in children, for clinically typical cases, the risk of melanoma is rare. Propranolol has been found to work in infantile haemangiomas by vasoconstriction of the vessels feeding the tumour and also by suppressing vascular endothelial growth factor.3 Propranolol is a noncardioselective beta-blocker that has revolutionized the treatment of haemangiomas. Systematic reviews have shown their efficacy and safety.1 Topical timolol has more recently been reported in the treatment of more superficial infantile haemangiomas particularly in the face and periocular region.4 Preparations prescribed have included gel or ophthalmic solution at a strength of 05%. In the past 2 years
British Journal of Dermatology (2014) 171, pp1537–1538
1 Izadpanah A, Izadpanah A, Kanevsky J et al. Propranolol versus corticosteroids in the treatment of infantile haemangiomas: a systematic review and meta-analysis. Plast Reconstr Surg 2013; 131:601–13. 2 Chan H, McKay C, Adams S, Warqon O. RCT of topical timolol gel for superficial infantile haemangiomas in 5- to 24-week-olds. Pediatrics 2013; 131:1739–47. 3 Greenberger S, Bischoff J. Pathogenesis of infantile haemangioma. Br J Dermatol 2013; 169:12–19. 4 Pope E, Chakkittakandiyil A. Topical timolol gel for infantile haemangiomas: a pilot study. Arch Dermatol 2010; 146:564–5. 5 Chakkittakandiyil A, Phillips R, Frieden IJ et al. Timolol maleate 0.5% or 0.1% gel-forming solution for infantile haemangiomas, a retrospective, multicentre cohort study. Pediatr Dermatol 2012; 29:28– 31. 6 Khorsand K, Maier M, Brandling-Bennett HA. Pyogenic granuloma in a 5-month-old treated with topical timolol. Pediatr Dermatol 2014. doi: 10.1111/pde.12297 (in press).
© 2014 British Association of Dermatologists
British Journal of Dermatology
CASE REPORT
A pyogenic granuloma treated with topical timolol M. Malik and R. Murphy Department of Dermatology, Queens Medical Centre, Nottingham University Hospital, Nottingham NG7 2UH, U.K.
Summary Correspondence Moona Malik. E-mail: [email protected]
Accepted for publication 6 May 2014
Funding sources None.
Conflicts of interest
Pyogenic granulomas are benign vascular tumours usually surgically treated by excision or curettage. The only topical therapy reported to date is imiquimod 5% cream but it produces a marked inflammatory response with discomfort generally worse than simple surgical excision or curettage. Here we report the use of timolol 05% ophthalmic gel used successfully to treat a teenager with a clinically classical pyogenic granuloma on the finger. There were no reported adverse effects and the lesion completely resolved. It has not recurred after 7 months. Timolol may be an effective and preferable alternative treatment to surgery for a classical small pyogenic granuloma, particularly in children and young people.
None declared. DOI 10.1111/bjd.13116
What’s already known about this topic?
•
Beta-blockers, including topical timolol and propranolol, are effectively used in the treatment of infantile haemangiomas. The only reported medical therapy for pyogenic granulomas is imiquimod.
What does this study add?
•
This report acts as a proof of the concept that topical timolol may be an alternative therapeutic option for classical pyogenic granuloma, particularly in children and young people.
Pyogenic granulomas are lobular capillary haemangiomas most commonly treated surgically by curettage or excision. Surgery has the advantage of providing histological confirmation of the diagnosis, but is an invasive procedure and may not be necessary in clinically typical cases. Beta-blockers, both systemic and topical, have been used effectively in the treatment of infantile haemangiomas, generally without prior histological confirmation of the diagnosis.1 While the majority of the evidence is with systemic agents such as propranolol, there is a growing literature for the use of topical agents such as timolol for small superficial lesions.2 Infantile haemangiomas and pyogenic granulomas have different pathogenesis and behaviour. However, both are benign proliferative vascular neoplasms and hence we tried timolol 05% gel for the treatment of a clinically classical pyogenic granuloma occurring on the finger of a child. There was complete resolution of the lesion after 3 weeks of twicedaily topical treatment with topical timolol 05% gel. Topical timolol might be a useful option for clinicians when treating classical pyogenic granulomas particularly in children and young people.
Case report
© 2014 British Association of Dermatologists
British Journal of Dermatology (2014) 171, pp1537–1538
A 14-year-old child presented with a 2-month history of a new vascular lesion on the index finger of the right hand. This bled easily and was increasing in size. Examination showed a 1-cm vascular nodule on the medial aspect of the distal phalanx of the right index finger, clinically consistent with a pyogenic granuloma (Fig. 1). This was treated with timolol 05% ophthalmic gel, twice a day, for 2 weeks. At follow-up, a 90% improvement was noted, and another week of treatment advised. The lesion completely resolved and had not recurred at 7 months (Fig. 2).
Discussion Pyogenic granuloma is a benign vascular proliferation that commonly affects the fingers, hands, forearms and face. It is also called a lobular capillary haemangioma owing to its histological features. Spontaneous resolution is rare. Bleeding and secondary infection are common complications. A differential 1537
1538 Pyogenic granuloma treated with topical timolol, M. Malik and R. Murphy
Fig 1. Pyogenic granuloma at presentation.
there have been several case reports, case series, prospective and retrospective studies, and a randomized controlled trial (RCT) supporting its use.2,5 To the best of our knowledge, only one case has been reported so far about the use of topical timolol for a pyogenic granuloma.6 Topical timolol was used for a month on the cheek of a 5-month-old infant with no recurrence of the pyogenic granuloma after 8 months. We are aware that the limitations of this case are the lack of histology, and would advocate the need for surgical treatment for histological confirmation if there was no response to therapy after 3 weeks of twice-daily use. Also, it would be particularly important to select only clinically typical cases. Without further evidence from case series or RCTs, we do not advocate its routine use. However, with the fear of surgery and low risk of melanoma in children, this may prove to be a useful therapeutic option. A case series with more information about treatment regimen and long-term recurrence would be needed before it could be recommended as an alternative to surgery. However, it might prove to be a useful alternative to surgery in children who present with classical, small, uncomplicated pyogenic granulomas.
References
Fig 2. Resolved pyogenic granuloma after topical timolol gel.
diagnosis includes amelanotic melanoma but in children, for clinically typical cases, the risk of melanoma is rare. Propranolol has been found to work in infantile haemangiomas by vasoconstriction of the vessels feeding the tumour and also by suppressing vascular endothelial growth factor.3 Propranolol is a noncardioselective beta-blocker that has revolutionized the treatment of haemangiomas. Systematic reviews have shown their efficacy and safety.1 Topical timolol has more recently been reported in the treatment of more superficial infantile haemangiomas particularly in the face and periocular region.4 Preparations prescribed have included gel or ophthalmic solution at a strength of 05%. In the past 2 years
British Journal of Dermatology (2014) 171, pp1537–1538
1 Izadpanah A, Izadpanah A, Kanevsky J et al. Propranolol versus corticosteroids in the treatment of infantile haemangiomas: a systematic review and meta-analysis. Plast Reconstr Surg 2013; 131:601–13. 2 Chan H, McKay C, Adams S, Warqon O. RCT of topical timolol gel for superficial infantile haemangiomas in 5- to 24-week-olds. Pediatrics 2013; 131:1739–47. 3 Greenberger S, Bischoff J. Pathogenesis of infantile haemangioma. Br J Dermatol 2013; 169:12–19. 4 Pope E, Chakkittakandiyil A. Topical timolol gel for infantile haemangiomas: a pilot study. Arch Dermatol 2010; 146:564–5. 5 Chakkittakandiyil A, Phillips R, Frieden IJ et al. Timolol maleate 0.5% or 0.1% gel-forming solution for infantile haemangiomas, a retrospective, multicentre cohort study. Pediatr Dermatol 2012; 29:28– 31. 6 Khorsand K, Maier M, Brandling-Bennett HA. Pyogenic granuloma in a 5-month-old treated with topical timolol. Pediatr Dermatol 2014. doi: 10.1111/pde.12297 (in press).
© 2014 British Association of Dermatologists
