Derm: Pyogenic granuloma: Free MSRA Podcast

✅ MSRA Deep Dive: Pyogenic Granuloma – Rapid Red Lesions Made Simple

In this high-yield episode, we break down pyogenic granuloma, a common and exam-relevant dermatological lesion. Despite the name, it’s not infectious and not a true granuloma. We clarify what it really is, why it forms, how to manage it, and how to confidently tell it apart from dangerous mimics like melanoma or SCC—critical for both safe practice and MSRA success.

🧠 Key Learning Points

📌 Definition
• Benign vascular tumour – fast-growing overgrowth of capillaries
• Not associated with pus or granulomatous inflammation
• Also called lobular capillary haemangioma

📌 Pathophysiology
• Triggered by minor trauma, hormonal changes, or certain medications
• Local healing response becomes overactive → dense growth of blood vessels
• Classic feature: rapid growth, friable, bleeds easily

🧪 Causes & Triggers
• Minor skin trauma, cuts, friction
• Hormonal changes – especially pregnancy
• Medications: retinoids, protease inhibitors, some chemo agents
• Possibly associated with Staph aureus, though less clearly proven

👩‍⚕️ Who Gets It?
• Bimodal peak: young children (esp. age 6–7) and young women
• Common in pregnancy and in people with prior skin irritation
• Often linked to oral contraceptives

🔍 Clinical Features
• Bright red or reddish-brown nodule
• Common on fingers, face, lips, scalp, and oral mucosa
• Typically painless but bleeds easily
• Grows rapidly over days to weeks
• Polypoid or “mushroom-like” shape is typical
• May ulcerate or develop satellite lesions after trauma

⚠️ Differential Diagnoses
• Amelanotic melanoma – red, non-pigmented but malignant
• Squamous cell carcinoma, Kaposi’s sarcoma, angiosarcoma
• Hemangioma, bacillary angiomatosis, infected skin lesions
💡 Always biopsy if diagnosis is unclear or lesion is atypical

🧪 Diagnosis
• Primarily clinical, but biopsy is crucial to rule out malignancy
• Histology confirms lobular capillary growth
• Dermoscopy is less useful (too vascular, patternless)
• Always send lesion for histology if excised or treated

💊 Management
• Watch and wait if small, especially in pregnancy (often regress post-delivery)
• Excision or curettage + electrocautery preferred for tissue diagnosis + treatment
• Other options: cryotherapy, laser, topical beta blockers (e.g. timolol), imiquimod
• For large or bleeding lesions → surgical removal is best
• Avoid cryotherapy if histological confirmation needed
• Wound care and follow-up essential to monitor healing and recurrence

📈 Prognosis
• Excellent – completely benign
• Most respond well to treatment
• Recurrence common if base not fully treated (deep vascular roots)
• Lesions linked to pregnancy often resolve postnatally

⚠️ Complications
• Bleeding, ulceration
• Cosmetic concerns

Episode Transcript

(00:00):
Welcome to the Deep Dive. We're doing something a little
different today. We're taking content you, the
listener sent in and turning it into a really focused, high
yield revision session aimed squarely at the MSRA.
Yeah, think of it as your personal audio flash card.
Almost. Exactly.
And today's topic, pyogenic granuloma, our mission basically

(00:20):
is to cut through all the detail, pull out the absolute
must know facts for the exam andyou know, make it stick.
No dry lectures, just a clear breakdown.
And it's a great choice for MSRAfocus.
Pyogenic granuloma is common, you'll definitely see it, and it
pops up in exam questions quite a bit.
Dermatology, GP stuff. It really tests if you can spot

(00:40):
it, know what it does, and crucially, tell it apart from,
well, nastier things. Getting this right?
Definitely good for your score. OK, let's dive right in then.
The absolute first hurdle with this one is the name.
Isn't it pyogenic granuloma? It sounds infectious or like
some specific inflammation, but that's not quite right.
That's the perfect starting point, actually, because it

(01:02):
yeah, the name is, well, seriously misleading.
Pyogenic makes you think plus infection.
Granuloma suggests a specific inflammatory reaction either.
Nope, neither. What it is is a common and this
is key, benign vascular tumour skin or mucous membranes.
It's basically a really rapid overgrowth of tiny blood

(01:23):
vessels, capillaries and some inflammatory cells mixed in.
So you'll see this like fast growing red or maybe reddish
brown bump sometimes. It's called
Granulomatalangitaticum too. Maybe slightly more accurate,
hinting at the blood vessel. Thing right,
Granulomatalangitaticum. So benign vascular tumour.
Got it. If the name's wrong and it's not
infection, what does trigger this?

(01:46):
You know, the sudden burst of growth.
Yeah, good question. The exact why isn't always
crystal clear, but it often seems to be a reactive thing,
like an over the top reaction tosomething pretty minor.
Minor like. A tiny cut, bit of skin
irritation, maybe bumping yourself, even an insect bite
sometimes. But, and this is interesting,
they're also really strong linksto hormonal changes and certain

(02:07):
drugs. Hormonal changes.
You mentioned pregnancy earlier.Yes, pregnancy is a classic
trigger. They're much more common then
other things linked are, like ongoing inflammation in an area
or maybe some underlying vascular issue there already.
There's some research hinting staph aureus might be involved,
maybe on irritated skin or possibly even viruses, but

(02:29):
that's less certain. What's clearer is the medication
link. Which meds?
Things like retinoids, some protease inhibitors used in HIV
treatment, certain chemotherapy agents.
So if you see a patient on one of those who suddenly develops
this lesion, well, that could bethe connection.
You know, OK, that makes sense. So building on those triggers,

(02:50):
minor trauma, hormones, specificmeds, who's most likely to get
one? Are there definite risk factors
we should? Know, absolutely.
I mean, anyone can get one, any age, any gender.
But yeah, they definitely cluster in certain groups.
Kids for one, often around say six or seven years old.
And women get them more than men.
Which ties back to the hormones,doesn't it?

(03:10):
Especially during pregnancy or even puberty.
Trauma is a general risk factor too, and those meds we just
mentioned, oral contraceptives are specifically noted as well.
Oh, and having pre-existing vascular weirdness in an area
might make you more prone too. So kids, pregnant women, people
on certain meds or after minor trauma.
Got it. Let's dig into the how a bit.

(03:31):
How does it actually happen? The Pathophysiology.
Right. So think of it as that abnormal
response. Again, your body gets a little
locked, right? It starts the healing process,
making new blood vessels, calling in inflammatory cells,
normal stuff. But with pyogenic granuloma in
that one spot, the process just goes haywire.
It doesn't stop. Instead of controlled you get
this like uncontrolled excessiveexplosion of capillaries in the

(03:54):
cells around them, plus loads ofinflammatory cells just hanging
about. So it just doesn't switch off.
Pretty much why that happens in response to something minor in
one person and not another, or why hormones seem to flick that
switch. Well, that's the bit we don't
fully get. But the core process
Uncontrolled reactive blood vessel growth.
Like that analogy we talked about before.

(04:15):
A tiny scratch that decides to build a dense little city of
blood vessels instead of just patching itself up.
That really helps. Picture it.
OK, now probably the most critical bit for the MSRA and
just, you know, safe practise telling things apart.
What else could this rapidly growing red bleedy bump be?
What are the differential this is?
Absolutely crucial because yeah,PG is benign, fine, but several

(04:38):
really serious things can look quite similar, especially early
on and particularly in adults. Like what?
So you got to consider other vascular things like hemagiomas,
but the big worry is skin cancer.
We're talking Kaposi sarcoma, angiosarcoma, even squamous cell
carcinoma can sometimes look like an angry red lump that
grows fast. And really importantly,
Melanoma. Melanoma.

(04:59):
But aren't they usually dark? Often, yes, but there's a type
called hypomelanotic or amyelotic Melanoma.
It lacks the dark pigment, so itcan present as a pink or red
bump that grows. That's a major pitfall.
OK. So that's why biopsy keeps
coming up, right? It's not just confirming PG,
it's ruling out these other potentially life thrilling
things. Exactly, biopsy is vital,

(05:20):
especially in adults or if lesion looks a bit odd, changes
really fast, or just doesn't quite fit that perfect PG
picture. Ruling out malignancy is
priority #1. OK, let's try a quick MSRA style
scenario then. Picture this GP clinic, a say 70
year old man worked outdoors foryears comes in.
He's got this red lesion on his scalp, grew quickly over the

(05:41):
last month, bleeds if he catchesit on a comb.
Based on that, pyrogenic granuloma is on the list, but
what are you really worried about?
Spot on that scenario, the age, the sun exposure history, the
location. Scalp gets lots of sun, the
rapid growth, the bleeding, it just screams.
Think differentials. PG is possible sure, but
squamous cell carcinoma high up there, Melanoma.

(06:01):
Absolutely need to rule it out. That patient needs a biopsy like
yesterday. Perfect, shows how you apply it.
OK. Stepping back slightly,
epidemiology, how common are these in the UK and the age
profile? Yeah, it's considered pretty
common here. And like we touched on, it often
has this sort of bimodal thing going on, peaks in two main
groups. Right, the kids in.
Exactly. Young kids, often around six or

(06:23):
seven, and then again in young adults, particularly women,
tying into those hormonal factors like pregnancy.
So yeah, anyone can get one, butthose are your classic
demographics. OK, now let's paint a really
clear picture. What do you actually see and
maybe feel in clinic? The key clinical features?
OK, so typically they start small, just a few millimetres,

(06:43):
but the growth is rapid, days toweeks.
That's a hallmark there. Raised bumps on skin or inside
the mouth for example. Colour usually bright red, maybe
darker red or reddish brown. Packed with blood vessels.
Remember the surface can be smooth but often it gets a bit
eroded or ulcerated. And crucially, they are very
friable. Friable, meaning easy to bleed.

(07:05):
Exactly, they bleed super easily.
Slightest knock, bit of frictionand they bleed often.
That's why people come in. They often look Polly Point.
Like a little mushroom, yeah. Kind of like a little mushroom
or Raspberry on a stock. Usually just one but size
varies. Common spots, hands, fingers are
classic. Face, inside the mouth, gums

(07:26):
especially in pregnant women. Head, neck, upper body, arms,
legs, even genitals during pregnancy.
Usually painless, which is interesting right?
But they can be uncomfortable ifthey rub on things and the
bleeding is obviously annoying or worrying.
Oh, and one thing to watch for, particularly in teens or young
adults. Sometimes after you try and
treat one little satellite lesions can pop up around the

(07:47):
edges. OK so that classic picture rapid
growth, red maybe stalk bleeds like crazy and that memory tip
seems useful here. PG pregnancy link.
Rapid growth, usually painless polypoid shape, prone to
bleeding. Covers the basics.
Nicely. Yeah, that sums it up well.
So you see this lesion look suspicious.
How do you actually investigate?What tests do you do?

(08:08):
Well, often the initial diagnosis is clinical.
Look at it, hear the story. Fast growth bleeds easily and
yeah, pygenic granuloma shoots up the list.
But like we hammered home biopsywith Histology is really
strongly recommended. To be absolutely sure.
To be sure, and critically to rule out those mimics,
especially cancer, looking at the cells under the microscope

(08:31):
is definitive. The notes mentioned
immunohistochemistry, sometimes for specific markers, but that's
less routine. And interestingly, dermoscopy.
The little handheld microscope thing.
Yeah, that it might not actuallybe that helpful here.
Why is that? Well, because the lesion is just
so full of blood vessels under the dermoscope it often just
looks like, well, a red vascularmass.

(08:53):
It can hide the patterns you normally look for to tell it
apart from other things like Melanoma.
So useful for lots of skin lesions, but maybe less so for a
class of PG. Good to know.
So clinical suspicion high but ideally biopsy for the final
word and cancer check right diagnosis confirmed it is a
pieogenic granuloma. How do we manage it?
What's the plan? Management really hangs on a few
factors. Where is it?

(09:14):
How big is it? Is it causing bother like
bleeding a lot? Okay, for really small ones,
sometimes they can just go away on their own, so watchful
waiting might be an option, especially if it's tiny and not
causing issues. And remember the pregnancy ones,
They often shrink right down after the baby's born.
Yes, so they might not need treatment.
Exactly, worth waiting if possible, but for bigger ones or

(09:37):
ones that just won't stop bleeding or look awful or get in
the way, then yeah, you need to intervene and there are quite a
few ways to do it. Like what?
Common options are things like cryotherapy, freezing it off,
electrocautery, using heat to burn it away.
Laser therapy is another one, oryou can physically remove it.
Cut it out. Yeah, excisional surgery.
Cut it out, maybe stitch your skin closed or methods like

(10:00):
curettage and cautery where you scrape the lesion off then burn
the base. That helps stop bleeding and
tries to get any deeper bits to stop it coming back.
Shave excision is similar. There are also some creams or
gels, Mickey mud cream, Timolol gel, other topical beta
blockers. Sometimes even oral beta
blockers are used, maybe more inkids if they have lots of them.

(10:21):
Oh, and steroid injections into the lesion are another
possibility. Wow, quite a list.
Any key things when choosing? Well, remember the biopsy point.
If you freeze it with cryotherapy, you don't get a
sample to send to the lab. Right.
So if there's any doubt about the diagnosis, choosing
something like excision or curetage where you get tissue at
the same time as treating it is probably smarter.

(10:44):
Also, just a specific point, that drug, sodium tetradecyl
sulphate, it's used for veins sometimes but it's not licenced
for PGS in the UK. Just one of those little exam
facts, perhaps? Good specific point and after
treatment wound care is important.
Absolutely. Keep it clean, prevent
infection, help it heal nicely, minimise scarring and follow up
is key to you need to check it'shealed completely.

(11:05):
And big point here, check it hasn't come back.
Recurrence is actually, well, pretty.
Common. Oh really?
Why did they come back so often?It seems to be because those
abnormal blood vessels can go deeper than you think, like
little roots under the surface bump.
If the treatment doesn't ZAP or remove all that deeper vascular
stuff, yeah, it can just regrow.So treatments like curetage plus

(11:27):
burning the base or full excision are maybe better at
preventing that. They aim to be, yeah, trying to
get the whole depth. Referral might be needed
sometimes too. The notes mentioned referring if
you're just not sure what it is,again, that malignancy concern,
or if you do suspect Melanoma. Obviously also if it keeps
coming back after treatment or for those little umbilical
granulomas and newborns that won't stop weeping.

(11:49):
Key times to get a specialist opinion.
OK. Nearly there.
Bringing it to a close, what's the overall outlook?
The prognosis generally, it's excellent.
It is benign. Remember most PGS respond really
well to treatment. Complete resolution is the norm.
You just need to warn patients about that recurrence
possibility, especially if triggers are still there like
hormones or irritation. But yeah, mostly sorted

(12:10):
successfully and those pregnancyones often just disappear post
delivery which is great. And finally, any complications,
even rare ones. Uncommon but yeah possible.
The bleeding is the main one. Sometimes it can be quite
dramatic. Ulceration of the surface can
happen, like any skin procedure.Tiny risk of infection or
scarring and if it's big or somewhere obvious, cosmetics can

(12:33):
be a concern. Usually with proper treatment
and follow up these are minimised.
Right, so there we have it, a deep dive into pyogenic
granuloma, really honed for MSRArevision.
We've unpacked what it is, what it definitely isn't, the
triggers, who gets it, what it looks like, the crucial
differentials, investigations, all those management options,
the generally good outlook and potential complications.

(12:56):
I think for the MSRA the absolute core things are spot
the classic picture rapid red bleeder, but always have
malignancy on your differential especially in adults and know
that biopsy is often needed to rule it out.
That's non negotiable really. Definitely.
And maybe a final thought for you to Mull over as you revise.
We talked a lot about hormones, pregnancy, certain meds, all
influencing this condition. Why is that link so strong?

(13:19):
What does it tell us about the underlying drivers of this crazy
blood vessel growth? Could figuring that out lead to,
I don't know, new treatments down the line?
Something to think about for more free MSR a revision
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