Pyogenic granuloma – Nd:YAG laser treatment in 450 patients

Abstract Background and objective: Pyogenic granuloma (PG) also known as “eruptive hemangioma”, “granulation tissue-type hemangioma”, “granuloma gravidarum”, or “lobular capillary hemangioma”, are well-demarcated, rapidly exophytic growing benign, usually pedunculated red (vascular) tumors on skin or mucosa. They belong to the group of capillary angiomas, but differ from infantile hemangioma. Occurrence is mostly posttraumatic, but also spontaneously, especially in children and pregnant women. A high risk of complication as bleeding or infection results from the vulnerable surface. Conventional surgical excision, cautery or cryotherapy may lead to relapse in addition to visible scar formation. Thus we remove PGs using laser, in most of cases with a continuous wave Nd:YAG laser. Methods: Before therapy, PGs of skin were initially rated in size and vascularization using color-coded duplex sonography. Usually the Nd:YAG laser (1064 nm) was employed. Laser settings and techniques were adjusted appropriately; i.e. pulsed, chopped or continuous wave for in-situ coagulation, in impression technique or by direct coagulation. Bigger and more pedunculated tumors have been coagulated at the base in a perpendicular fashion with bare fiber. The present paper is a retrospective cohort study of PGs which have been treated since the year 2000 in our clinic at the Ev. Elisabeth Klinik Berlin, Germany. In order to review our learning curve, the patients were divided into two groups according to the period of treatment: 1) patient group between the years 2000–2004; 2) patient group between the years 2005–2013. Results: In total, 450 patients with 454 PGs were treated between the years 2000–2013. The size of PGs at time of treatment was 2–15 mm. Forty percent of PGs showed former bleeding. Seventy-six percent (n=344) of PGs occurred during the first two decades of life; 60% of cases in this group (n=205) occurred during the first 5 years of age. Taken as a whole, no gender predominance (♂: 52%; ♀: 48%) was found. Interestingly in the first year of age there was a male predominance (♂: 61%); in contrary a female predominance (♀: 63%) in middle age was seen. Eighty percent of angiomas were located in the head-neck region, particularly on eyelids. In the years 2000–2004, 70% of cases were treated with the Nd:YAG laser; a single session was sufficient in 93% of this cases, and the recurrence rate was 7%. In contrast, in the years 2005–2013, Nd:YAG laser treatment was performed in 94% of cases with a recurrence rate of less than 4%. The most effective application mode was the use of the Nd:YAG bare fiber technique, for both coagulation in situ and radical removal with <1% recurrences. No complications such as postoperative bleeding or infection appeared. Clinical outcome was scored by two independent evaluators blinded to type and number of treatments by rating the postoperative control images and could be completed for 199 out of 450 patients. The cosmetic results, especially in the facial area (containing lips and eyelids), were good or excellent in 60% of the cases (n=120). Conclusions: Laser treatment proved to be a successful method with no relevant side effects or complications. Scarring was observed in 40% of the cases (n=79) and thus less compared with shave excision and cautery. Hence, it can be suggested to include the Nd:YAG laser into the options of first-line therapy for PGs.