Plantar pyogenic granuloma successfully treated with table salt

Introduction

Pyogenic granuloma is an uncommon vascular tumour arising on the skin. Its sudden appearance and growth, along with spontaneous bleeding and pain can be alarming for the patient. Traditional treatment has focussed on excision or curettage under local anaesthesia. The authors report a plantar lesion successfully treated at home by the patient using daily application of salt over a two-week period.

Pyogenic granuloma on the heel

Case Report

An 82-year-old male presented to the podiatry clinic requesting treatment for a verruca on his left foot diagnosed by his general practitioner. On the GP’s advice, he had been applying topical salicylic acid, but the lesion had responded to treatment.

The patient vaguely recalled a penetrating injury to the heel, three months earlier and latterly the  development of the lesion, from a black dot, at the site of injury. The GP had reviewed the heel and suggested it may have been a verruca and suggested topical over-the-counter medications.

On examination:

The lesion presented as a discrete, raised, fleshy vascular nodule, separate from the surrounding tissue. The surrounding skin was macerated and sloughy due to the previous application of salicylic acid (Figure 1). Minor trauma from examination led to copious bleeding from the lesion which was difficult to stop.

Previous Medical History:

Hypertension, severe osteo-arthritis both knees, previous R tibial fracture (pinned), recent urinary tract infection.

Medication:

Amitriptyline, Amlodipine, Candesartan, Doxazosin, Epimax cream, Simvastatin and Trimethoprim

Differential diagnosis:

From the presenting history and clinical appearance, a preliminary diagnosis of pyogenic granuloma (PG) was made. Amelanotic melanoma, although rare, was considered as a possible differential diagnosis based on the clinical appearance and age of the patient.

Management of Pyogenic Granuloma

Following  an email consultation with colleagues, it was decided to treat the lesion as a PG using a regime of daily salting of the lesion, as outlined by the Primary Care Dermatology Website (Figure 2).

Figure 2 : Excerpt from the PCDS.org.uk website

As the excerpt above highlights, although the diagnosis is often straightforward the main differential diagnosis is that of a hypomelanotic melanoma, which tend to bleed less than pyogenic granuloma. Other features that may increase the level of suspicion include no clear history of trauma and an atypical site or age group. To this end, in the UK, where there is any diagnostic uncertainty patients are best referred urgently to secondary care, typically through the patients General Practitioner for diagnosis and treatment.

Protocol for Pyogenic Granuloma Treatment

Initially, Vaseline was applied around the lesion to mask the intact skin from salt, The top of a plastic syringe was applied as a cup around the PG and secured with tape. The cup was then filled with table salt  (Figure 3a). The area was closed with tape and surrounded by an adhesive 7mm semi-compressed felt pad (Figure 3b). The patient was rebooked for three days later.

Figure 3 : Syringe tip in secured in place over the lesion.

At the next appointment, 3 days later, the patient reported removing the plastic syringe tip as it was coming loose but had continued salting the lesion. The PG looked smaller with no evidence if recent bleeding (Figure 4). The area was cleaned and the process repeated, replenishing salt, re-securing with padding and strapping, this time without the syringe tip.

A further 3 days later, the re-dressing process was repeated, and the lesion photographed. Fragility was noted in the lesion, and it showed evidence of disintegration (Figure 5). The patient was advised to continue salting daily.

Figure 4 : 1st redressing after 3 days of salt application

At the third review appointment, three weeks later, the patient reported the lesion had dropped off leaving a small hole (Figure 6). The area had completely resolved (Figure 6) a few weeks after at his final review before discharge.

Figure 5 : Lesion after 2 applications of salt.

Figure 6 : Crater left after lesion disintegrated.

Discussion

PG (also known as lobular capillary haemangioma) is a common benign, vascular lesion of the skin and mucous membranes. They can occur at any age although they are most common in childhood and pregnancy. Under half of patients report a history of localised trauma before their development.  The lesion is composed primarily of a proliferation of blood vessels hence their ability to bleed easily. In addition, they may exude serous fluid [1]. Lesions appear on the skin or around the nail, without or without a history of trauma. This is the first reported case of PG arising on the plantar surface of the foot. 

Figure 7 : Complete healing of the area

Consideration at the time of diagnosis was given to the possibility of acral amelanotic melanoma, although the clinical picture favoured PG, it should always be considered for unusual pink lesions arising on the plantar surface. It was decided to treat it as a PG with salt and if no clinical response had been observed in a two-week period, a referral could have been made to dermatology under the two-week wait, as documented by the Primary Care Dermatology Website [2] .

Traditional treatments include excision, injection of sclerosants, laser and cryosurgery. Treatments that allow histology have historically been preferable, in order to rule out accidental destruction of amelanotic melanoma.

The use of salt to treat PG was first proposed by Schmitt [3] for umbilical granulomas, although recently there has been a resurgence in interest in the use of salt in the literature. One of the largest studies prospectively treated PG in 50 patients using white soft paraffin occlusion around the lesion and table salt. All lesions (100%) had resolved in around 14 days with no complications or scarring [4].

The case presented by the authors here, demonstrates these that lesions arising on the sole can be successfully treated, without surgery, using this method without complications and without the need for histology.

References

1.           Scheinfeld, N.S., Pyogenic Granuloma. SKINmed, 2008. 7(1): p. 37-39.

2.           Cunliffe, T. Pyogenic Granuloma. 2023  [cited 2024 July]; Available from: https://www.pcds.org.uk/clinical-guidance/pyogenic-granuloma.

3.           Schmitt, B., Tip of the month, shrinking umbilical granulomas. Consultant, 1972. 12: p. 91.

4.           Daruwalla, S.B., S. Ghate, and R. Dhurat, Establishing the efficacy and safety of the novel use of common salt for the treatment of pyogenic granuloma. Clinical and Experimental Dermatology, 2021. 7(1):1243-1247.

Authors notes:

The patient gave full consent for this case to be published.

The article will be published in the forthcoming PCDS bulletin.