Which treatment modality of pyogenic granuloma is worth its weight in salt?

By Warren R. Heymann, MD, FAAD
July 31, 2024
Vol. 6, No. 31

I get palpitations with every pyogenic granuloma (PG) I encounter. Even though the clinical diagnosis is instant, my personal Jiminy Cricket dermatologist reminds me not to miss an amelanotic melanoma, squamous cell carcinoma, or cutaneous metastasis. If I remove it, will it be a bloody mess? On most occasions, I get the anxious patient (who wouldn’t be worried about a rapidly appearing nodule that constantly bleeds?) and myself to take a breath, relax, remove the lesion under local anesthesia, cauterize the base, and submit the friable lesion for histopathologic confirmation. That is the ideal scenario. As every dermatologist knows, life is not always so straightforward. What are therapeutic alternatives to PGs when surgical removal may not be desired by the patient, parent, or even clinician?

PGs are common, benign vascular proliferations of the skin and mucous membranes. PGs mostly affect children, adolescents, and young adults, particularly pregnant women. Lesions typically present as rapidly growing erythematous nodules that may develop into pedunculated tumors with an erosive surface and tendency to bleed. Lesions usually appear on the head, neck, fingers, and toes. Mucosal lesions most commonly involve the oral gingiva but may also appear on the lips, tongue, buccal mucosa, palate, and rarely in the nasal cavity. (1) Michael Fisher, the chief of dermatology at Albert Einstein College of Medicine during my residency, would remind us that the term PG is a misnomer — it is not pyogenic or a granuloma. Histologically, the lesion consists of lobular aggregates of capillary-sized vessels, often displaying a central feeder vessel. In practice there is little need for immunohistochemical stains, but if obtained (for atypical or equivocal cases), PGs stain positive for the vascular markers CD31, CD34, and factor VIII antigen, but negatively for glucose transporter-1 (GLUT­1). (2)

The precise etiology of PGs is unknown, although lesions are associated with pregnancy, trauma, and immunosuppression. Vascular growth may be regulated by vascular endothelial growth factor (VEGF) and influenced by hormones such as estrogen and progesterone. (1, 3) Drug-induced PGs have been reported with 6 classes of medications; 1) cancer therapeutics, including chemotherapy (5-fluorouracil, capecitabine, others), EGFR inhibitors (cetuximab, gefitinib), cancer antibody treatments (rituximab), BRAF inhibitors, and mTOR inhibitors; 2) antiretrovirals (indinavir, lamivudine); 3) oral to topical retinoids (isotretinoin, acitretin, tretinoin, tazarotene); 4) immunosuppressants (cyclosporine); 5) hormones (erythropoietin, levothyroxine, contraceptives); and 6) anticonvulsants (carbamazepine). (3)

Regarding management of PGs, Sarwal and Lapumnuaypol aptly state: “Clinical trials are limited, and hence there is no accepted standard of care for treating these lesions. Different treatments have variable degrees of success and variable rates of recurrence. No matter the treatment, the patient should be counseled about the risk of recurrence.” (4)

Surgical approaches (complete excision, shave excision, electrodessication), chemical cauterization with silver nitrate, cryosurgery, sclerotherapy (polidocanol, sodium tetradecyl sulfate, bleomycin), lasers (pulsed dye, 810-diode, Nd:YAG, Erbium:YAG, CO2), photodynamic therapy, and radiation therapy have all been utilized. (1,5,6,7)

Topical therapies that may be beneficial for PGs include corticosteroids, 5% imiquimod, and beta-blockers (timolol, propranolol). (1,3,8) The title of this commentary posed the question of which treatment for PG is worth its weight in salt? The answer may be — salt itself.

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Salt has been used therapeutically for dermatologic disorders since antiquity; its diverse uses in traditional and modern medicine are thoroughly reviewed by Moanoharan and Kaliaperumal. (9) Based on the previously reported use of salt for treating umbilical granulomas with salt, Daruwalla and Dhurat reported the successful use of common table salt in 5 patients with a PG. White soft paraffin was used to protect surrounding normal skin. Complete resolution of lesions occurred by 7 to 14 days, depending on the size of the lesion. A mild burning sensation was experienced at the time of the first application in 2 patients who had a raw, bleeding area; however, no other adverse effects were encountered. No recurrence of lesions occurred at 1 month of follow-up. (10) The presumption is that the hyperosmolar milieu from salt causes desiccation and shrinkage of the lesion. In a follow-up study, Daruwalla et al performed a prospective open-label uncontrolled study of 50 PG patients was conducted with salt as previously described (using occlusion with surgical tape). Complete resolution of the lesion without any residual scar was seen in 100% of the cases; 94% reported a decrease in the bleeding tendency of the lesion as an immediate response. The mean time to complete resolution was 14.77 days. Recurrence was noted in one patient after 11 months of resolution. The authors concluded: “Owing to the relative ease in application, lack of scarring and excellent response, we consider salt application to be an ideal treatment for PG lesions, especially in children and anxious patients reluctant to undergo any procedure.” (11)

In conclusion, should I ever confront a PG that is not amenable to removal and histologic confirmation (and I hope never to be in that position), I will strongly consider peppering it with salt. Further studies will be needed to confirm if you need a tad (1/4 tsp), dash (1/8 tsp), pinch (1/16 tsp), smidgen or shake (1/32 tsp), or drop or nip (1/64 tsp)! (12)

Point to Remember: There are many modalities to treat pyogenic granulomas. If removal of the lesion is impractical, and salt is as effective as preliminary studies suggest, it will be worth its weight in salt, indeed.

Our expert’s viewpoint

Andrew C. Krakowski, MD, FAAD
Network Chair of Dermatology
Program Director for the Residency in Dermatology
St. Luke’s University Health Network
Bethlehem, Pennsylvania

As a pediatric dermatologist, I get a lot of pyogenic granulomas coming through my door. It’s like our waiting room is a veritable salt lick, attracting affected children — usually about 5 minutes before closing time. The classic “band-aid” sign gives the kids away and contributes to an acute spike in my medical team’s collective blood pressure — they know what is coming.

My go-to management approach is not for the faint of heart. Like Dr. Heymann, who is salt of the earth, I opt for shave removal with desiccation. I start by injecting the lesion’s base locally with lidocaine and epinephrine utilizing a 90-degree angle to the skin. First, I inject quickly and deeply to get the nerves and feeder vessel. As I start to see some local vasoconstriction, I flatten out my injection angle and use the local anesthesia to create a more biopsy-friendly “mesa.” I give the epinephrine 5-10 minutes to work its vasoconstrictive magic. That ensures a much less bloody field and buys me some time to calm the child with a lollipop and an engrossing smartphone video of their choice. Next, I shave the lesion at the base and expose the feeder vessel. Depending on the vessel’s size and depth, I may use a 3mm curette to scrape the base and expose it further still. Then, I use electrocautery to desiccate the culprit vessel, and I try to get out of the exam room with my eardrums still intact. I always thank the family for the opportunity to know, in advance, what I will be having a nightmare about later that evening.

Over the years, we have been peppered with innovative alternatives to this cold steel approach. So, why do we put ourselves and our patients through it? Because amelanotic melanoma is a real and deadly thing, and it can look just like a PG — especially in kids! Consequently, I want histological confirmation of what I am treating before I take my patients down the wrong path.

It is said that spilling salt will bring you bad fortune. The idea of ditching my bland but time-tested approach for Drs. Daruwalla and Dhurat’s salt technique seems the perfect recipe for disaster. I don’t want to rub salt into an open wound but deviating from the “shave and desiccation” method not only fails to provide histological confirmation — it may also lull you into a false sense of security when the lesion in question, whatever it happens to be, starts to shrivel in response to topical salt application. Take this with a grain of salt, but this seems like a bad idea all around, not the least of which is medico-legally.

So, you want to know if I am going to shake up my well-seasoned approach to managing PGs? To quote the salty sailor, “Na, I’m good.”¹¹

¹¹ Sodium’s atomic number.

1. Plachouri KM, Georgiou S. Therapeutic approaches to pyogenic granuloma: an updated review. Int J Dermatol. 2019 Jun;58(6):642-648. doi: 10.1111/ijd.14268. Epub 2018 Oct 21. PMID: 30345507.

2. Sarwal P, Lapumnuaypol K. Pyogenic Granuloma. 2020 Dec 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 32310537.

3. Moustafa D, Neale H, Ostrowski SM, Gellis SE, Hawryluk EB. Topical corticosteroids for noninvasive treatment of pyogenic granulomas. Pediatr Dermatol. 2021 Jul 16. doi: 10.1111/pde.14698. Epub ahead of print. PMID: 34272756.

4. Thomas M, Shon W, Truong AK. Acitretin-induced periungual pyogenic granulomas and review. Dermatol Online J. 2021 Jul 15;27(7). doi: 10.5070/D327754369. PMID: 34391333.

5. Sarwal P, Lapumnuaypol K. Pyogenic Granuloma. 2020 Dec 5. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 32310537.

6. Khurana A, Mathachan SR. Efficacy of bleomycin as a treatment modality in pyogenic granuloma: a case series. Dermatol Ther. 2021 Jul;34(4):e15024. doi: 10.1111/dth.15024. Epub 2021 Jun 15. PMID: 34089553.

7. Pisano M, Sammartino P, Di Vittorio L, Iandolo A, Caggiano M, Roghi M, Bizzoca ME, Lo Muzio L. Use of Diode Laser for Surgical Removal of Pyogenic Granuloma of the Lower Lip in a Pediatric Patient: A Case Report. Am J Case Rep. 2021 Jun 19;22:e929690. doi: 10.12659/AJCR.929690. PMID: 34146391; PMCID: PMC8218884.

8. Jaiswal H, Patidar N, Shah C, Singh R, Jain E, Piyush P. Topical timolol 0.5% as the primary treatment of ophthalmic pyogenic granuloma: A prospective, single-arm study. Indian J Ophthalmol. 2021 May;69(5):1155-1160. doi: 10.4103/ijo.IJO_2404_20. PMID: 33913850; PMCID: PMC8186631.

9. Manoharan P, Kaliaperumal K. Salt and skin. Int J Dermatol. 2021 Apr 22. doi: 10.1111/ijd.15588. Epub ahead of print. PMID: 33890287.

10. Daruwalla SB, Dhurat RS. A pinch of salt is all it takes! The novel use of table salt for the effective treatment of pyogenic granuloma. J Am Acad Dermatol. 2020 Aug;83(2):e107-e108. doi: 10.1016/j.jaad.2019.12.013. Epub 2019 Dec 12. PMID: 31838042.

11. Daruwalla SB, Ghate S, Dhurat R. Establishing the efficacy and safety of the novel use of common salt for the treatment of pyogenic granuloma. Clin Exp Dermatol. 2021 Oct;46(7):1243-1247. doi: 10.1111/ced.14658. Epub 2021 May 10. PMID: 33764555.

12. https://www.tasteofhome.com/article/whats-the-difference-between-a-pinch-a-dash-and-a-shake/ (accessed October 3, 2021).

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