Letters: Clarification on pyogenic granuloma treatment

I was concerned to see cryotherapy listed as acceptable management of pyogenic granuloma (GP, 24 October). A significant differential diagnosis is the deadly amelanotic melanoma. Freezing yields no histology, which is mandatory here.

If a positive diagnosis is made, pyogenics can be curetted and sent for histology, but I would never consider freezing one.

The lesion featured as a pyogenic granuloma is a deeply pigmented and ulcerated nodule which I think looks like a melanoma. I have treated dozens of pyogenic granulomas but never seen one this colour.

This lesion should be referred urgently to a skin cancer clinic. The idea of freezing a nodular, ulcerated, deeply pigmented lesion would rightly horrify any dermatologist and is medico-legally indefensible.

Dr Stephen Hayes, GPSI in dermatology, Hospital Practitioner (skin cancer), Trustee, Primary Care Dermatology Society, Southampton.

Response from author Dr Vasa Gnanapragasam, Sutton, Surrey

Thank you for these comments. Dr Hayes makes two valid points. The first is that the image published as an example was not typical. While I accept that this was probably not the best example for this feature, the lesion pictured was in fact confirmed histologically as a pyogenic granuloma.

Nevertheless, lesions such as this should be referred urgently to a pigmented lesion clinic.

The second relates to the recommendation of cryotherapy as treatment. Dr Hayes is absolutely correct to point out that cryotherapy does not provide a histological specimen. It is not advisable for lesions where there is any doubt about the diagnosis.

Cryotherapy has been used in the past for small pyogenic granulomas where the practitioner is confident of the diagnosis, but in light of NICE guidelines on lesions where skin cancer needs to be excluded, it is mandatory to refer cases such as this urgently to a dermatologist.

In this feature, cryotherapy was listed as a management possibility for an experienced clinician to determine rather than as a recommendation for this particular illustration, but admittedly this should have been clarified.

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