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Surgical Pearl: Ligation of The Base of Pyogenic Granuloma-An Atraumatic, Simple, and Cost-Effective Procedure

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Surgical Pearl: Ligation of The Base of Pyogenic Granuloma-An Atraumatic, Simple, and Cost-Effective Procedure

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gabbyneng
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J AM ACAD DERMATOL Pearls 509

VOLUME 49, NUMBER 3

Stuart J. Salasche, MD Surgical Pearls Editor Mark G. Lebwohl, MD Medical Pearls Editor

Surgical Pearl: Ligation of the base of pyogenic


granuloma—An atraumatic, simple, and
cost-effective procedure
Hans C. Hölbe, MD, Peter J. Frosch, MD, and Rudolf A. Herbst, MD
Dortmund, Germany

P yogenic granuloma (PG, granuloma pyogeni-


cum, granuloma telangiectaticum, lobular cap-
illary hemangioma) is a common, benign, ac-
quired vascular tumor mostly presenting as a rapidly
growing red and sometimes pedunculated papule (Fig
1, A). It can occur at any age but most frequently
affects younger children. Often minor injury or infec-
tion are described as triggers. The tumors are prefer-
entially located on the face or extremities. If untreated,
the lesions tend to persist, frequently ulcerate, and are
prone to spontaneous or traumatic bleeding. Com-
monly described treatment options are complete sur-
gical excision, shave excision, or curettage followed by
electrodesiccation, various forms of laser operation,
cryotherapy, or injection of sclerosing agents.1-3 We
describe an atraumatic, simple, fast, and cost-effective
alternative treatment option.
The PG is ligated as closely as possible to its base
using soft (absorbable) surgical suture material (eg,
Resorba 3-0 D-90475, Resorba Wundversorgung,
Nuremberg, Germany) (Fig 1, B). This maneuver can
be facilitated by lifting the PG with forceps. The
tumor is then ligated with knots that are as tight as
possible and the suture material is snipped so short
that it will not irritate the surrounding skin (eg,
periorbital). The ligated tumor can be covered by a
wound dressing. The tumor will become necrotic
and fall off in several days. Patients, parents, or both
need to be advised that bleeding could occur from
the nurturing blood vessel. This unusual event can
be controlled by self-applied simple compression of

From the Department of Dermatology, Klinikum Dortmund gGmbH


and University of Witten/Herdecke.
Funding sources: None.
Conflict of interest: None identified.
Reprint requests: Rudolf A. Herbst, MD, Hautklinik, Klinikum Dort-
mund gGmbH, Beurhausstrasse 40, D 44137 Dortmund, Ger-
many. E-mail: [email protected].
J Am Acad Dermatol 2003;49:509-10.
Copyright © 2003 by the American Academy of Dermatology, Inc. Fig 1. Pyogenic granuloma in a 10-year-old girl before (A),
0190-9622/2003/$30.00 ⫹ 0 shortly after (B), and 6 weeks after (C) base ligation with
doi:10.1067/S1090-9622(03)00030-6 a 3-0 suture.
510 Pearls J AM ACAD DERMATOL
SEPTEMBER 2003

the lesion for several minutes. Only clinically obvi- This smaller lesion can be easily treated, eg, by laser
ous cases of PG should be treated by this technique operation (eg, a high-energy long-pulsed frequency-
because no histologic examination will be available. doubled Nd:YAG laser) or light electrodesiccation.
This procedure is very simple, fast, and can be A persisting vessel can also cause recurrences as
performed even in small children (our youngest pa- described after shave excision or curettage followed
tient was 2 years old). No anesthesia is required be- by electrodesiccation.1 We believe, however, that
cause it is atraumatic. It is particularly suited for pe- the technique described herein should be consid-
dunculated lesions and in areas where operation may ered as a treatment of first choice for pedunculated
be complicated, such as close to the eyelid as in the PGs because it is much less traumatic for younger
patient presented herein. This 10-year-old girl (Fig 1) patients. It is so simple and fast that it can be per-
was scheduled for operation under general anesthesia formed in any dermatologist’s office, and it is less
by the ophthalmology department, but came to see a expensive than most alternatives. In case of persis-
dermatologist (R.A.H.), for a second opinion. Her PG tence or recurrence of the PG, complete excision
became necrotic within 5 days after ligation. There was can still be performed.
no residual PG 6 weeks later and the tumor did not recur.
One potential hazard of this technique is the lack REFERENCES
of a histologic examination because among the dif- 1. Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular cap-
ferential diagnoses for PG are malignant tumors illary hemangioma): a clinicopathlogic study of 178 cases. Pedi-
such as amelanotic melanoma. However, this should atr Dermatol 1991;4:267-76.
not pose a problem in the hands of experienced 2. Matsumoto K, Nakanishi H, Seike T, Koizumi Y, Mihara K, Kubo Y.
dermatologists who will only treat clinically obvious Treatment of pygenic granuloma with a sclerosing agent. Der-
matol Surg 2001;27:521-3.
cases by this technique. 3. Raulin C, Greve B, Hammes S. The combined continuous-wave/
Because the ligature may not reach far enough pulsed carbon dioxide laser for treatment of pyogenic granu-
down to the nurturing vessel, part of it may persist. loma. Arch Dermatol 2002;138:33-7.

Direct all Medical Pearl submissions to


Direct all Surgical Pearl submissions to Dr
Mark G. Lebwohl, Mount Sinai Medical
Stuart J. Salasche, 5300 N Montezuma
Center, One Gustave L. Levy Place, Box
Trail, Tucson, AZ 85750. 1048, New York, NY 10029.

IOTADERMA #116
What is gleet?
Nikki Levin, MD, PhD
Answer will appear in the October issue of the Journal.

AUGUST IOTADERMA (#115)


What are SNARE proteins, and how do they pertain to dermatology?
Answer: They are the proteins that, when complexed, allow presynaptic
acetylcholine-containing vesicles to fuse with neuronal cell membranes and
thus permit synaptic activity. They are the proteins to which botulism toxins
cleave, which is how and why BOTOX works.

REFERENCES
Foran PG, Mohammed N, Lisk GO, et al. Evaluation of the therapeutic usefulness of
botulinum neurotoxins B, C1, E, F compared to the long-lasting type A: basis for
distinct durations of inhibition of exocytosis in central neurons. J Biol Chem 2002
Oct 14 [Epub ahead of print].
Rowland LP. Stroke, spasticity, and botulinum toxin. N Engl J Med 2002;347:382-3.

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