Granulomatous lesions

Contributed by Dr Jean Watkins, a retired GP in Hampshire.

Pyogenic granuloma

Pyogenic granuloma is a benign vascular lesion, particularly common in children and young adults. The cause is unknown but trauma, infection with Staphylococcus aureus, drugs and hormonal influences are possible triggers. A small red, brown or bluish spot rapidly progresses within a few weeks to a painless red papule or nodule that bleeds on trauma or spontaneously. Common sites to be affected are the hands, fingers, head, neck, feet or mucosal surfaces. Treatment includes curettage and cautery, laser treatment, cryotherapy if lesions are small, silver nitrate, imiquimod or surgical excision.

Umbilical granuloma

After delivery, the umbilical cord normally separates within eight days and heals within two weeks. In the presence of skin infection, there may be delay in separation, inflammation develops at the umbilicus and leads to excess granulation. The pink/red, glistening granulomatous tissue protrudes from the umbilicus. Many resolve spontaneously but if persistent, the application of a small pinch of salt to the granuloma, before covering it with gauze for half an hour, helps promote shrinkage. This may be repeated twice daily for three days, being careful not to damage surrounding skin.

Localised granuloma annulare

Localised granuloma annulare (GA) is benign inflammatory dermatosis. It may occur at any age but is common in children and young adults. This patient displays the localised type of GA as a solitary annular ring on the finger. It can affect the extensor surfaces of the limbs, or dorsal surfaces of the hands and feet. Groups of asymptomatic papules form an arc around a central depression. A clinical diagnosis is possible but, if necessary, the diagnosis can be confirmed by biopsy. Spontaneous resolution occurs in half the cases but some lesions may last for weeks or years.

Fish tank granuloma

Fish tank granuloma is caused by mycobacterium marinum and can be caught by those involved with exposure to contaminated fresh or salt water; for example, cleaning out a fish tank in which fish are infected. The patient may present with a lump, pustule or abscess that breaks down leaving open sores. Spread of lesions along the line of lymphatic drainage then follows. Treatment requires antibiotics for at least eight weeks. Tetracycline, fluoroquinolones, macrolides or sulfonamides are usually effective together with an antimycobacterial drug, such as rifampicin.

Excess granulation tissue

Granulation tissue normally develops during the wound healing process. The tissue may vary in colour from pink to bright red, it is soft to the touch, moist, with a granular surface and a tendency to bleed easily. Sometimes, as in this patient who had sustained a wound to the toe, the granulation tissue will be excessive, stand proud from the skin and may be mistaken for a pyogenic granuloma. Protective dressings of hydrocolloid or foam may be recommended. Recognise secondary infection if exudates or darkening of the tissues occurs.

Spectacle granuloma (Acanthoma fissurAtum)

Chronic trauma and pressure of spectacle frames may lead to the development of a thickened plaque of tissue at the site. The areas usually affected are on top of or behind the ear, or over the bridge of the nose. The patient may complain of discomfort when wearing glasses and on examination a thickened plaque with a linear grove running through it may be seen. Occasionally it may be necessary to excise the lesion but the condition can normally be improved by changing to spectacles with a lighter frame.

Generalised granuloma annulare

Similar lesions may occur but with a more widespread distribution. The pink or mauve 'rings' may spread and coalesce, forming annular plaques mainly on the limbs and trunk, but any part of the body may be affected. Generalised GA is sometimes associated with diabetes mellitus or HIV. Urine should be checked repeatedly to exclude diabetes and the necessary investigations pursued if HIV infection is a possibility. Treatment is frequently unnecessary as resolution may occur within a few months, with no residual scarring.

Cutaneous sarcoidosis

Sarcoidosis affects many organs, including the skin. The cause is unknown but is thought to be a disorder of the immune system. In about a third of those with skin involvement, other organs remain unaffected but further tests may be needed. Skin lesions may take the form of red/purple nodules, thickened plaques or infiltration of old scars. This man presented with a persistent plaque. Skin biopsy confirmed the diagnosis of cutaneous sarcoid. Referral to a chest physician was made when X-ray showed lung involvement with multiple nodules. A topical steroid was prescribed for the skin lesions.

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