Pyogenic Granuloma A pyogenic granuloma (also called lobular capillary hemangioma ) is a benign vascular lesion most commonly found on exposed skin surfaces such as the face, hands, and forearms Occasionally, lesions form on oral or nasal mucosal surfaces They are composed of granulation tissue with significant vascular overgrowth and are considered the result of an exaggerated vascular growth factor response after local trauma Lesions are usually solitary and pedunculated, measuring from 0.5 to cm At times, multiple satellite lesions are found around a central granuloma The color and character of a pyogenic granuloma varies according to its stage of growth Early on, the lesion appears as a glistening, red, polypoid nodule with a friable surface that bleeds easily Over weeks to months, most lesions become fibrotic and shrink, taking on a reddish-brown hue The most common reasons for presenting to the ED are bleeding or chronic oozing of an early lesion Treatment in the ED consists of control of bleeding by direct pressure or silver nitrate cauterization of vessels at the base Hemostatic dressings may also be helpful Topical, intralesional, and systemic medical therapy have been reported However, given high reoccurrence rates, surgical excision by a specialist is the preferred treatment Umbilical Granuloma An umbilical granuloma presents as a soft, friable, polypoid mass that is pink or dull red As oppose to omphalitis, umbilical granulomas have a nonpurulent odorless discharge These lesions arise from the base of the umbilical stump after cord detachment and at times may be pedunculated with a short stalk ( Fig 120.18 ) They develop as the product of an exuberant granulation tissue reaction, probably secondary to excessive moisture and/or low-grade infection Histology shows vascular endothelial cells and fibroblasts Treatment of most lesions consists of cauterization with silver nitrate During this procedure, care should be taken to cover the skin of the umbilical rim with gauze and/or petroleum jelly to protect it from chemical burns Following cauterization, the lesion should be blotted dry to avoid seepage of excess silver nitrate to surrounding tissue which can lead to hyperpigmented staining Home care consists of keeping the umbilicus clean and dry Large granulomas may require repeated cautery at intervals of several days Pedunculated granulomas are candidates for suture ligation (3-0 nylon) The parent is then instructed to return for follow-up for cauterization of the base (once the granuloma has necrosed and fallen off) to prevent recurrence Umbilical granulomas must be differentiated from a persistent embryonic remnant such as an omphalomesenteric duct or patent urachus The