Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Art & Psychiatry
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Conference Oration
Conference Summary
Continuing Medical Education
Cosmetic Dermatology
Current Best Evidence
Current Issue
Current View
Derma Quest
Dermato Surgery
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
Editor Speaks
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Miscellaneous Letter
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News & Views
Observation Letter
Observation Letters
Original Article
Original Contributions
Pattern of Skin Diseases
Pediatric Dermatology
Pediatric Rounds
Presedential Address
Presidential Address
Presidents Remarks
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Review Article
Review Articles
Reviewers 2022
Revision Corner
Self Assessment Programme
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Study Letter
Study Letters
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Systematic Review and Meta-Analysis
Systematic Reviews and Meta-analyses
Systematic Reviews and Meta-analysis
Therapeutic Guideline-IADVL
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapy Letter
Therapy Letters
View Point
What’s new in Dermatology
View/Download PDF

Translate this page into:

Net Letter
doi: 10.4103/ijdvl.IJDVL_80_17
PMID: 29547139

Recurrent pyogenic granuloma over nevus flammeus

Sharma Shruti1 , Fouzia Siraj1 , Vasanthi Ramesh2 , V Ramesh2
1 Department of Pathology, National Institute of Pathology, ICMR, Safdarjung Hospital, New Delhi, India
2 Department of Surgery, VMMC, Safdarjung Hospital, New Delhi, India

Correspondence Address:
Fouzia Siraj
National Institute of Pathology, ICMR, Safdarjung Hospital, New Delhi
How to cite this article:
Shruti S, Siraj F, Ramesh V, Ramesh V. Recurrent pyogenic granuloma over nevus flammeus. Indian J Dermatol Venereol Leprol 2019;85:236
Copyright: (C)2019 Indian Journal of Dermatology, Venereology, and Leprology


Pyogenic granuloma is an acquired reactive vascular proliferation in the skin and oral mucosa, commonly affecting the children and young adults.[1] It has been infrequently reported in association with other vascular abnormalities such as nevus flammeus and vascular hemangiomas, especially after laser therapy.[2] Various vascular neoplasms like capillary hemangiomas, tufted angiomas, and cavernous hemangiomas, have been rarely associated with port-wine stain (PWS), also a type of nevus flammeus.[3] The occurrence of recurrent pyogenic granuloma in association with such vascular lesions is rare. Few of them have arisen in nevus flammeus without any predisposing factor like trauma, laser treatment, or pregnancy.[2] This spontaneous development may be promoted by arteriovenous anastomoses in vascular lesions, especially in the richly vascularized areas like fingers, hands, lips, tongue and face leading to the development ofpyogenic ranuloma.[4] We hereby report an unusual case of spontaneously recurrent pyogenic ranuloma within a nevus flammeus in the absence of any predisposing factor and further discuss their relationship with arteriovenous malformations.

A 26-year-old male presented to us with a single, 2 × 3 cm dark red, dome-shaped pedunculated growth within a congenital, Diffuse pale red patch extending irregularly over the left upper thigh. [Figure - 1]a and [Figure - 1]b. The growth was non-pruritic with occasional episodic spontaneous bleeding. Our presumptive diagnosis was pyogenic granuloma or an infected acrochordon over a nevus flammeus. The lesion recurred two times despite excision. The excised lesion was sent to National Institute of Pathology for histopathology. Microscopic examination showed a vascular lesion surrounded by hyperplastic epithelium with parakeratosis and focal ulceration. Dermis revealed lobules of variably sized capillaries in a fibromyxoid matrix with admixed inflammatory cells. Some vessels were congested and lined by plump endothelial cells [Figure - 2]. A diagnosis of pyogenic granuloma was rendered, which. is a rapidly growing, hypervascular, hemorrhagic lesion that presents as a painless, reddish purple, pedunculated, or sessile mass. The size can vary in different patients but usually never exceeds 2 cm.[1] Clinically there has been no recurrence four months post surgery. Most of these lesions arising on nevus flammeus/port wine stain are located outside the distribution of the trigeminal nerve like neck, trunk, or extremities.[2] The pathogenesis of most sporadic pyogenic granulomas and those arising on nevus flammeus remains elusive. Pyogenic granuloma, a reactive vascular tumor and nevus flammeus, a vascular malformation arise via different processes with complex regulatory mechanisms that are under study. Both are vascular lesions and despite having distinct clinical, histopathological, and biological characteristics, these are rarely associated with one another.[4] Our association could be explained by the development of pyogenic granuloma in microscopic arteriovenous anastomoses in vascular lesions, and also by its association with arteriovenous hemangiomas. Another hypothesis says that since pyogenic granulomas are noninfectious, purulent lesions, they develop as reactive inflammatory masses of blood vessels and fibroblasts within the dermis. With the etiology not being fully understood, an unknown stimulus triggers endothelial cell proliferation and angiogenesis leading to a rapidly growing lesion.[1] More recently, few studies have indicated that abnormalities in embryonic vasculogenesis leads to vascular malformations such as nevus flammeus/port wine stain and may further predispose to the development of vascular hyperplasias or tumors.[2] Chemical mediators like inducible nitric oxide synthase have also been implicated in their formation.[2] A study reported 10 pyogenic granulomas secondarily arising over a port wine stain; 8 cases showing BRAF mutation, one case NRAS mutation and GNAQ mutation each. Similar mutations were identified in both the lesions indicating their common origin.[5]

Figure 1:
Figure 2: Vascular lesion lined by hyperplastic epithelium with focal parakeratosis and ulceration. Dermis reveals lobules of small capillaries (H&E, 100×)

There are several methods for treating pyogenic granuloma but recurrence is a major problem for patients. Various therapeutic modalities include excision, curettage, sclerotherapy, radiotherapy, electrocautery, and use of lasers.[1],[2] In the present case, only excisional biopsy was performed for treatment and was not followed by cautery or laser therapy. A recent clinical report presented the successful use of a sclerosing agent ethanolamine for treatment of recurrent pyogenic granuloma associated with port wine stain.[6]

In our case pyogenic granuloma developed de novo, in the absence of any predisposing factor, probably resulting from an underlying arteriovenous anastomosis associated with nevus flammeus. This occurrence offers unique insight into the pathogenesis of these poorly understood but commonly encountered entities.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Akbulut F, Akbulut T, Kucukdurmaz F, Sonmezay E, Simsek A, Gurbuz G, et al. Huge pyogenic granuloma of the penis. Case Rep Urol 2015;2015:263168.
[Google Scholar]
Sheehan DJ, Lesher JL Jr. Pyogenic granuloma arising within a port-wine stain. Cutis 2004;73:175-80.
[Google Scholar]
da Silva AD, Silva CA, de Camargo Moraes P, Thomaz LA, Furuse C, de Araújo VC, et al. Recurrent oral pyogenic granuloma in port-wine stain. J Craniofac Surg 2011;22:2356-8.
[Google Scholar]
Aghaei S. Pyogenic granuloma arising in port-wine stain after cryotherapy. Dermatol Online J 2003;9:16.
[Google Scholar]
Groesser L, Peterhof E, Evert M, Landthaler M, Berneburg M, Hafner C, et al. BRAF and RAS mutations in sporadic and secondary pyogenic granuloma. J Invest Dermatol 2016;136:481-6.
[Google Scholar]
Deore GD, Gurav AN, Patil R, Shete AR, NaikTari RS, Khiste SV, et al. Sclerotherapy: A novel bloodless approach to treat recurrent oral pyogenic granuloma associated with port-wine stain. Ann Vasc Surg 2014;28:1564.e9-14.
[Google Scholar]

Fulltext Views

PDF downloads
Show Sections