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Growing Plantar Lesion Following Trauma



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Am Fam Physician. 2006 Oct 1;74(7):1173-1174.

A healthy 21-year-old woman presented with a growing “blister” on the undersurface of her right big toe. She first noticed the lesion about two weeks earlier. One week before the lesion appeared, the woman stepped on a piece of glass and injured herself in the same spot. She completely removed the piece of glass. The patient denied having any constitutional symptoms or significant medical history. On examination, a 1.5-cm × 1.5-cm, erythematous, dome-shaped lesion was noted on the plantar surface of the toe (see accompanying figure). It had a moist, glistening surface that bled easily when touched.

Question

Based on the patient’s history and physical examination, which one of the following is the most likely diagnosis?

A. Amelanotic melanoma.

B. Cherry angioma.

C. Pyogenic granuloma.

D. Kaposi’s sarcoma.

E. Bacillary angiomatosis.

Discussion

The answer is C: pyogenic granuloma. A pyogenic granuloma, also known as granuloma telangiectaticum or lobular capillary hemangioma, is a rapidly developing capillary hemangioma.1 The term pyogenic is a misnomer because the lesion is not caused by an infectious process.1,2 These lesions are typically bright red, dome shaped, and have a moist (occasionally scaling) surface that is friable and bleeds easily when traumatized. These solitary lesions usually, but not always, are preceded by trauma and develop over a few weeks. They occur more commonly during pregnancy, possibly because of the proliferative effects of estrogens. Pyogenic granulomas may persist for several months.

Pyogenic granulomas are treated by excision with curettage of the base and the border. Their vascular nature may necessitate electrodesiccation and curettage to eliminate abnormal tissue and control bleeding. Curettage is essential because the smallest fragment of abnormal tissue can cause recurrence.2 Pyogenic granulomas have no potential for malignant transformation; tissue diagnosis is recommended only when clinical uncertainty exists. Patients should be advised of the benign nature of the lesion but should be warned that recurrence is possible.

Amelanotic melanomas do not grow rapidly, but they may resemble pyogenic granulomas clinically because they are nodular. If amelanotic melanoma is suspected, a sample should be submitted for pathologic examination.13

Cherry angiomas are benign lesions that tend to occur in persons older than 30 years. The lesions range from single to multiple deep red papules. Cherry angiomas most commonly are smooth and flat or slightly raised but also can be large and polypoid. They always blanch with pressure.4 In contrast to pyogenic granulomas, cherry angiomas grow slowly and are not as friable.

Kaposi’s sarcoma is a vascular neoplasm occurring in patients who are positive for human immunodeficiency virus infection and in older, predominantly male patients of Jewish, Greek, or Italian descent.3 These lesions appear as violaceous macules and papules that progress to form plaques with multiple purple-red nodules.

Bacillary angiomatosis is caused by two species of Bartonella, with skin inoculation occurring via a cat bite or scratch. It almost exclusively affects patients with acquired immunodeficiency syndrome and is highly unusual in an immunocompetent host.1,2 Solitary or multiple firm red lesions may resemble pyogenic granulomas. If the lesions are multiple and widespread, systemic illness can be present.

Selected Differential Diagnosis of Enlarging Raised, Erythematous Skin Lesions

Condition Characteristics

Amelanotic melanoma

Nodular, slow-growing lesion, no preceding trauma

Cherry angioma

Usually multiple, deep red, smooth papules

Pyogenic granuloma

Solitary, bright red, dome-shaped lesion; moist, glistening surface; bleeds easily on touch; usually preceded by trauma

Kaposi’s sarcoma

Violaceous macules and papules, later changing to plaques and multiple purple-red nodules

Bacillary angiomatosis

Solitary or multiple lesions resembling pyogenic granulomas; follows a cat bite or scratch

Selected Differential Diagnosis of Enlarging Raised, Erythematous Skin Lesions

View Table

Selected Differential Diagnosis of Enlarging Raised, Erythematous Skin Lesions

Condition Characteristics

Amelanotic melanoma

Nodular, slow-growing lesion, no preceding trauma

Cherry angioma

Usually multiple, deep red, smooth papules

Pyogenic granuloma

Solitary, bright red, dome-shaped lesion; moist, glistening surface; bleeds easily on touch; usually preceded by trauma

Kaposi’s sarcoma

Violaceous macules and papules, later changing to plaques and multiple purple-red nodules

Bacillary angiomatosis

Solitary or multiple lesions resembling pyogenic granulomas; follows a cat bite or scratch

REFERENCES

1. Fitzpatrick TB. Color Atlas and Synopsis of Clinical Dermatology: Common and Serious Diseases. 5th ed. New York, N.Y.: McGraw-Hill, 2005:184–5.

2. Habif TP, ed. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 4th ed. New York, N.Y.: Mosby, 2004:826–7.

3. Goldman L. Skin diseases of general importance–part 2. In: Goldman L, Bennett JC, eds. Cecil Textbook of Medicine. 21st ed. Philadelphia, Pa.: Saunders, 2000: 2289.

4. Goldstein BG, Goldstein AO. Benign neoplasms of the skin. In: Rose BD, ed. UpToDate. 2006. Accessed September 5, 2006, at: http://www.uptodate.com/.

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