CLINICALLY SPEAKING
Red, Exophytic Nodule of the Plantar Foot An Unusual Presentation of a Pyogenic Granuloma Mary-Margaret Kober, MD* Usha Alapati, MD*† Amor Khachemoune, MD*† Pyogenic granulomas are benign vascular tumors characterized histologically by a lobular proliferation of capillaries. We report an unusual presentation of a pyogenic granuloma in an elderly patient with a bleeding red nodule on the plantar surface of the foot. Nodular exophytic plantar foot lesions often present a diagnostic challenge, as the differential diagnosis includes benign and malignant entities ranging from eccrine poroma and pyogenic granuloma to Kaposi’s sarcoma and amelanotic melanoma. This case highlights the need for an adequate biopsy technique to confirm the diagnosis and guide management. (J Am Podiatr Med Assoc 105(2): 195-197, 2015)
Hartzell first used the term pyogenic granuloma in 19041; he believed that four cases of similarappearing lesions represented a nonspecific granulation tissue response to a pyogenic agent.2 Today, however, it is clear that the term pyogenic granuloma is a misnomer because no infectious agent has been identified and microscopic examination does not demonstrate a granulomatous proliferation.2 Histologically, pyogenic granulomas show a well-circumscribed proliferation of small capillaries grouped into lobules by fibrous bands with or without overlying ulceration.2 Histologic confirmation is often advocated, as one series showed that 18% of pyogenic granulomas were initially misdiagnosed.3 Pyogenic granulomas commonly present in children and young adults; the mean age at onset in children is 6.7 years.4 In contrast to oral mucosa pyogenic granulomas, which have a female-to-male predominance of 2:1, likely relating to pregnancy and oral contraceptive use, *Department of Dermatology, State University of New York Downstate Medical Center, Brooklyn, NY. †Department of Dermatology, Veterans Affairs Hospital Brooklyn, Brooklyn, NY. Corresponding author: Amor Khachemoune, MD, Dermatology Service, Veterans Affairs Hospital and SUNY Downstate, 800 Poly Pl, Brooklyn, NY 11209. (E-mail: amorkh@ gmail.com)
solitary cutaneous pyogenic granulomas do not show a sex predilection.4 Cutaneous pyogenic granulomas most commonly occur on the head and neck, although fingers are also frequently involved.2,4 Classically, pyogenic granulomas are rapidly growing, red, exophytic nodules that stabilize in size at approximately 1 cm. They have been associated with chronic low-grade trauma and certain drugs,5 most frequently systemic retinoids, epidermal growth factor receptor inhibitors, and indinavir.2 However, reports after hormone, docetaxel, and paclitaxel therapy have been documented.6,7 Spontaneous infarct and involution of pyogenic granulomas may rarely occur, 4 but definitive treatment is usually required. The lowest recurrence rate occurs with excision and linear closure,4 although shave excision followed by electrodessication of the base may be sufficient for most pyogenic granulomas.2 Newer therapies include sclerotherapy and 585-nm pulsed dye laser, although these modalities often require multiple treatments.4,8
Case Presentation An 83-year-old man with a medical history of advanced Alzheimer’s dementia, atrial fibrillation,
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hypertension, hyperlipidemia, and gastrointestinal bleed presented for evaluation of a red, exophytic nodule on the right plantar foot. Because of the patient’s severe dementia, the lesion duration was not readily discernible; however, the patient’s daughter first noticed the growth 2 months before the dermatologic evaluation. Since that time, the patient’s daughter believed that it had increased only minimally in size. The lesion was nontender and frequently bled when traumatized. Physical examination revealed a 1.9 3 1.2-cm ulcerated, bleeding, exophytic nodule on the right plantar foot overlying the second metatarsophalangeal joint (Fig. 1). There was a thick collarette of scale surrounding the lesion. No tenderness was noted on palpation. The clinical diagnoses included eccrine poroma, amelanotic melanoma, Kaposi’s sarcoma, and pyogenic granuloma. To obtain a final histologic diagnosis, an excisional biopsy was performed with approximately 1- to 2-mm margins from the sur-
rounding collarette of scale. Simple closure was performed using 3.0 monofilament polypropylene suture. Microscopic examination of representative hematoxylin and eosin–stained slides of the surgically excised specimen showed a proliferation of small capillaries lined by plump endothelial cells arranged in a lobular pattern and surrounded by a fibromyxoid stroma with overlying ulceration; the lateral margin was significant for epidermal acanthosis forming a collarette (Fig. 2). These findings confirmed the diagnosis of a pyogenic granuloma. Because the pyogenic granuloma had been completely excised with biopsy, no further treatment was required. The patient’s sutures were removed 2 weeks after the excisional biopsy was performed. The excisional site had healed well, with approximated wound edges and no evidence of residual disease, and the patient and family were reassured.
Discussion This case describes an unusual presentation of a pyogenic granuloma. In particular, the location on the plantar foot, the development in the ninth decade of life, and size greater than 1 cm are uncommon presenting features of a pyogenic granuloma. Furthermore, the patient was not taking any medication that may predispose to pyogenic granuloma development. Although this patient’s condition was benign and adequately treated with excisional biopsy, it is necessary to be aware of the broad differential diagnosis that characterizes solitary red nodules on the plantar foot, most notably eccrine poroma, Kaposi’s sarcoma, and amelanotic melanoma. Because the differential diagnosis includes malignant tumors, it is important to achieve an accurate and timely diagnosis to minimize potential morbidity or mortality. Histologic evaluation of the lesion is indicated to determine the correct diagnosis and, consequently, to ensure proper treatment and follow-up. This case illustrates the need for an effective biopsy technique given the significant role of histologic confirmation in managing patient care. Figure 1. Right plantar foot with a 1.9 3 1.2-cm
exophytic, ulcerated, red nodule surrounded by a thick collarette of scale.
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Financial Disclosure: None reported. Conflict of Interest: None reported.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
Figure 2. Ulcerated nodule consisting of proliferation of small capillaries surrounded by fibromyxoid stroma and an epidermal collarette (H&E, x2 [A and B], x10 [C], x40 [D]).
References 1. GOMES S, SHAKIR Q, THAKER T, ET AL: Pyogenic granuloma of the gingiva: a misnomer? a case report and review of the literature. J Ind Soc Periodont 17: 514, 2013. 2. NORTH P, KINCANNON J: ‘‘Vascular Neoplasms and Neoplastic-like Proliferations,’’ in Dermatology, 3rd Ed, edited by JL Bolognia, JL Jorizzo, JV Schaffer, p 1915, Elsevier Limited, Amsterdam, the Netherlands, 2012. 3. KIRSCHNER R, LOW D: Treatment of pyogenic granuloma by shave excision and laser photocoagulation. Plast Reconstr Surg 104: 1346, 1999. 4. LIN RL, JANNIGER CK: Pyogenic granuloma. Cutis 74: 229, 2004.
5. JAFARZADEH H, SANATHANI M, MOHTASHAM N, ET AL: Oral pyogenic granuloma: a review. J Oral Sci 48: 167, 2006. 6. PAUL LJ, COHEN PR: Paclitaxel-associated subungual pyogenic granuloma: report in a patient with breast cancer receiving paclitaxel and review of drug-induced pyogenic granulomas adjacent to and beneath the nail. J Drugs Dermatol 11: 262, 2006. 7. JOHNSON TM, DEMSAR WJ, HEROLD RW, ET AL: Pyogenic granuloma occurring in a postmenopausal woman on hormone replacement therapy. US Army Med Dep J (Jan-Mar): 86, 2011. 8. GONZALEZ S, VIBHAGOOL C, FALO LD JR, ET AL: Treatment of pyogenic granulomas with the 585 nm pulsed dye laser. J Am Acad Dermatol 35: 428, 1996.
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Red, Exophytic Nodule of the Plantar Foot An Unusual Presentation of a Pyogenic Granuloma Mary-Margaret Kober, MD* Usha Alapati, MD*† Amor Khachemoune, MD*† Pyogenic granulomas are benign vascular tumors characterized histologically by a lobular proliferation of capillaries. We report an unusual presentation of a pyogenic granuloma in an elderly patient with a bleeding red nodule on the plantar surface of the foot. Nodular exophytic plantar foot lesions often present a diagnostic challenge, as the differential diagnosis includes benign and malignant entities ranging from eccrine poroma and pyogenic granuloma to Kaposi’s sarcoma and amelanotic melanoma. This case highlights the need for an adequate biopsy technique to confirm the diagnosis and guide management. (J Am Podiatr Med Assoc 105(2): 195-197, 2015)
Hartzell first used the term pyogenic granuloma in 19041; he believed that four cases of similarappearing lesions represented a nonspecific granulation tissue response to a pyogenic agent.2 Today, however, it is clear that the term pyogenic granuloma is a misnomer because no infectious agent has been identified and microscopic examination does not demonstrate a granulomatous proliferation.2 Histologically, pyogenic granulomas show a well-circumscribed proliferation of small capillaries grouped into lobules by fibrous bands with or without overlying ulceration.2 Histologic confirmation is often advocated, as one series showed that 18% of pyogenic granulomas were initially misdiagnosed.3 Pyogenic granulomas commonly present in children and young adults; the mean age at onset in children is 6.7 years.4 In contrast to oral mucosa pyogenic granulomas, which have a female-to-male predominance of 2:1, likely relating to pregnancy and oral contraceptive use, *Department of Dermatology, State University of New York Downstate Medical Center, Brooklyn, NY. †Department of Dermatology, Veterans Affairs Hospital Brooklyn, Brooklyn, NY. Corresponding author: Amor Khachemoune, MD, Dermatology Service, Veterans Affairs Hospital and SUNY Downstate, 800 Poly Pl, Brooklyn, NY 11209. (E-mail: amorkh@ gmail.com)
solitary cutaneous pyogenic granulomas do not show a sex predilection.4 Cutaneous pyogenic granulomas most commonly occur on the head and neck, although fingers are also frequently involved.2,4 Classically, pyogenic granulomas are rapidly growing, red, exophytic nodules that stabilize in size at approximately 1 cm. They have been associated with chronic low-grade trauma and certain drugs,5 most frequently systemic retinoids, epidermal growth factor receptor inhibitors, and indinavir.2 However, reports after hormone, docetaxel, and paclitaxel therapy have been documented.6,7 Spontaneous infarct and involution of pyogenic granulomas may rarely occur, 4 but definitive treatment is usually required. The lowest recurrence rate occurs with excision and linear closure,4 although shave excision followed by electrodessication of the base may be sufficient for most pyogenic granulomas.2 Newer therapies include sclerotherapy and 585-nm pulsed dye laser, although these modalities often require multiple treatments.4,8
Case Presentation An 83-year-old man with a medical history of advanced Alzheimer’s dementia, atrial fibrillation,
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hypertension, hyperlipidemia, and gastrointestinal bleed presented for evaluation of a red, exophytic nodule on the right plantar foot. Because of the patient’s severe dementia, the lesion duration was not readily discernible; however, the patient’s daughter first noticed the growth 2 months before the dermatologic evaluation. Since that time, the patient’s daughter believed that it had increased only minimally in size. The lesion was nontender and frequently bled when traumatized. Physical examination revealed a 1.9 3 1.2-cm ulcerated, bleeding, exophytic nodule on the right plantar foot overlying the second metatarsophalangeal joint (Fig. 1). There was a thick collarette of scale surrounding the lesion. No tenderness was noted on palpation. The clinical diagnoses included eccrine poroma, amelanotic melanoma, Kaposi’s sarcoma, and pyogenic granuloma. To obtain a final histologic diagnosis, an excisional biopsy was performed with approximately 1- to 2-mm margins from the sur-
rounding collarette of scale. Simple closure was performed using 3.0 monofilament polypropylene suture. Microscopic examination of representative hematoxylin and eosin–stained slides of the surgically excised specimen showed a proliferation of small capillaries lined by plump endothelial cells arranged in a lobular pattern and surrounded by a fibromyxoid stroma with overlying ulceration; the lateral margin was significant for epidermal acanthosis forming a collarette (Fig. 2). These findings confirmed the diagnosis of a pyogenic granuloma. Because the pyogenic granuloma had been completely excised with biopsy, no further treatment was required. The patient’s sutures were removed 2 weeks after the excisional biopsy was performed. The excisional site had healed well, with approximated wound edges and no evidence of residual disease, and the patient and family were reassured.
Discussion This case describes an unusual presentation of a pyogenic granuloma. In particular, the location on the plantar foot, the development in the ninth decade of life, and size greater than 1 cm are uncommon presenting features of a pyogenic granuloma. Furthermore, the patient was not taking any medication that may predispose to pyogenic granuloma development. Although this patient’s condition was benign and adequately treated with excisional biopsy, it is necessary to be aware of the broad differential diagnosis that characterizes solitary red nodules on the plantar foot, most notably eccrine poroma, Kaposi’s sarcoma, and amelanotic melanoma. Because the differential diagnosis includes malignant tumors, it is important to achieve an accurate and timely diagnosis to minimize potential morbidity or mortality. Histologic evaluation of the lesion is indicated to determine the correct diagnosis and, consequently, to ensure proper treatment and follow-up. This case illustrates the need for an effective biopsy technique given the significant role of histologic confirmation in managing patient care. Figure 1. Right plantar foot with a 1.9 3 1.2-cm
exophytic, ulcerated, red nodule surrounded by a thick collarette of scale.
196
Financial Disclosure: None reported. Conflict of Interest: None reported.
March/April 2015 Vol 105 No 2 Journal of the American Podiatric Medical Association
Figure 2. Ulcerated nodule consisting of proliferation of small capillaries surrounded by fibromyxoid stroma and an epidermal collarette (H&E, x2 [A and B], x10 [C], x40 [D]).
References 1. GOMES S, SHAKIR Q, THAKER T, ET AL: Pyogenic granuloma of the gingiva: a misnomer? a case report and review of the literature. J Ind Soc Periodont 17: 514, 2013. 2. NORTH P, KINCANNON J: ‘‘Vascular Neoplasms and Neoplastic-like Proliferations,’’ in Dermatology, 3rd Ed, edited by JL Bolognia, JL Jorizzo, JV Schaffer, p 1915, Elsevier Limited, Amsterdam, the Netherlands, 2012. 3. KIRSCHNER R, LOW D: Treatment of pyogenic granuloma by shave excision and laser photocoagulation. Plast Reconstr Surg 104: 1346, 1999. 4. LIN RL, JANNIGER CK: Pyogenic granuloma. Cutis 74: 229, 2004.
5. JAFARZADEH H, SANATHANI M, MOHTASHAM N, ET AL: Oral pyogenic granuloma: a review. J Oral Sci 48: 167, 2006. 6. PAUL LJ, COHEN PR: Paclitaxel-associated subungual pyogenic granuloma: report in a patient with breast cancer receiving paclitaxel and review of drug-induced pyogenic granulomas adjacent to and beneath the nail. J Drugs Dermatol 11: 262, 2006. 7. JOHNSON TM, DEMSAR WJ, HEROLD RW, ET AL: Pyogenic granuloma occurring in a postmenopausal woman on hormone replacement therapy. US Army Med Dep J (Jan-Mar): 86, 2011. 8. GONZALEZ S, VIBHAGOOL C, FALO LD JR, ET AL: Treatment of pyogenic granulomas with the 585 nm pulsed dye laser. J Am Acad Dermatol 35: 428, 1996.
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