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Thalidomide shows Promise in Treating Pyogenic Granuloma on Upper Lip: Shenzhen Case Study
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Published: October 26, 2023
A recent case study conducted in Shenzhen, guangdong, People’s Republic of China, has revealed promising results for treating pyogenic granuloma (PG) using oral thalidomide.The 32-year-old male patient, who had a PG on his upper lip, experienced complete regression of the benign vascular tumor after conventional treatments like glucocorticoid injections and long-pulse 1064 nm laser therapy failed.The successful outcome, observed over a 3-year follow-up, suggests that thalidomide could offer an effective alternative, particularly for PGs located in aesthetically sensitive areas. This case highlights a potential new avenue for managing this common dermatological condition when other methods prove ineffective.
Pyogenic granuloma, also known as lobular capillary hemangioma, is a relatively common benign vascular proliferation. It manifests as rapidly growing, erythematous nodules that are prone to bleeding.These nodules frequently appear on the head and neck, including the oral gingiva and lips, but can also affect the limbs. While the precise cause of PG remains elusive, factors such as trauma, infection, hormonal imbalances, and certain medications are believed to contribute to its advancement.
Traditional treatments for PG encompass both surgical and non-surgical approaches. Surgical excision is frequently enough favored due to its high efficiency, low recurrence rate, and the chance for histopathological examination. However, surgery can be costly and may result in scarring, especially in delicate areas like the lips. Non-surgical options, including laser therapy, cryotherapy, glucocorticoid injections, and local administration of anticancer drugs, are less invasive but may have variable efficacy and potential side effects. For instance, glucocorticoid injections can led to atrophy or changes in skin pigmentation, while anticancer drug injections may cause local ulceration and scarring.
This particular case study delves into a patient whose PG proved resistant to these conventional treatments, prompting the exploration of thalidomide as a potential alternative.
Case Presentation
The 32-year-old man sought medical attention for a single, painless red nodule located on the middle of his upper lip. The nodule had been present for approximately two months.Initially, it presented as a small, corn-sized papule that bled easily upon touch. Due to the absence of discomfort,the patient initially did not seek medical intervention.
A physical examination revealed a solitary, hemispherical, red nodule measuring approximately 8 mm in diameter. The nodule exhibited a smooth, moist surface, telangiectasia (small, widened blood vessels), clear boundaries, and a soft texture that bled easily. A reflectance confocal microscopy (RCM) examination was also performed to further evaluate the lesion.
While excisional biopsy is a standard treatment modality for PG, allowing for both lesion removal and definitive diagnosis through histopathologic assessment, it was not pursued in this case due to the lesion’s location on the upper lip and the patient’s concerns about cosmetic outcomes. Instead, the diagnosis of pyogenic granuloma was made based on the typical clinical manifestations (hemispherical, red nodule, prone to bleeding, rapid growth), the RCM findings, and by differentiating it from other similar diseases.
Despite undergoing local injection of compound betamethasone and four sessions of long-pulse 1064 nm laser therapy over six months, the lesion showed no notable betterment. Given the PG’s location and the patient’s aesthetic concerns, the medical team opted for oral thalidomide treatment at a dose of 75 mg nightly for five months.
Treatment and Outcome
Following five months of oral thalidomide treatment, the lesion had flattened and decreased in volume, leaving onyl a faint scar. During this period, the patient experienced only mild xerostomia (dry mouth) without any other adverse effects. A three-year follow-up confirmed complete healing with no recurrence, and the patient expressed satisfaction with the treatment outcome.
Discussion: Thalidomide’s Potential
The existing medical literature lacks extensive evidence supporting the use of thalidomide in treating pyogenic granuloma. However, research suggests that PG pathogenesis is linked to high expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (FGF). Immunohistochemical analyses have also shown increased expression of cyclooxygenase-2 (COX-2) and Interleukin-10 (IL-10) in PG tissues compared to normal vascular tissue. Some studies have even linked mutations in genes like BRAF, RAS, and GNAQ to PG pathogenesis.
Thalidomide is known for its immunomodulatory and anti-angiogenic properties and is used in dermatology for conditions such as erythema nodosum leprosum, cutaneous sarcoidosis, lupus erythematosus, and other dermatological conditions that are refractory to conventional therapies. It is significant to note that the more common and unique side effects of thalidomide are teratogenicity and peripheral neuropathy.
Thalidomide exerts its therapeutic effects by modulating vascular and immune responses,demonstrating efficacy in various malignancies. It can suppress FGF-2 and VEGF, inhibiting tumor necrosis factor-alpha (TNF-α) synthesis and attenuating inflammation, angiogenesis, and immune responses. Thalidomide also impedes lipopolysaccharide-induced COX-2 expression, destabilizing mRNA and impeding prostaglandin E2 (PGE2) synthesis, further contributing to its anti-tumor and anti-inflammatory effects.
Conclusion: A Promising Alternative
In this particular case, the decision to use oral thalidomide was driven by the lesion’s location, which significantly affected the patient’s appearance, and the lack of improvement with local injection and laser treatment. The potential mechanisms of thalidomide in treating PG include inhibiting angiogenesis by suppressing VEGF and FGF, improving microvessel aggregation, and exhibiting anti-tumor effects. It can also degrade COX-2, inhibit tumor growth, and possess anti-inflammatory properties. Moreover, thalidomide modulates granulomatous inflammation by promoting immune cell recruitment and activity, while also regulating angiotensin-converting enzyme levels, perhaps inhibiting macrophage function.however, the specific mechanism still requires further research.
This case report demonstrates the successful use of thalidomide in treating PG, offering a potential therapeutic option for PG or hemangiomas in specific areas when other treatments have been unsatisfactory.
Thalidomide’s Unexpected Role: A New Hope for Pyogenic Granuloma Treatment?
Conventional treatments for pyogenic granuloma often fail, leaving patients with unsightly lesions and limited options. But a recent case study suggests a surprising new approach using thalidomide might change the game.
To gain further insight, we spoke with Dr. Anya Sharma, a leading dermatologist specializing in vascular proliferative disorders.
Interviewer: Dr. Sharma, can you explain what pyogenic granuloma is for our readers, and why existing treatments sometimes fall short?
Dr. Sharma: Thank you for having me. Pyogenic granuloma,also known as lobular capillary hemangioma,is a common benign vascular tumor characterized by a rapidly growing,red nodule often found in sun-exposed areas. It’s benign, meaning it’s not cancerous, but its appearance can be highly distressing, particularly when located on visible areas like the face or lips. Existing treatments, like surgical excision, while effective, can lead to noticeable scarring, especially on sensitive areas. Non-surgical methods such as laser therapy, cryotherapy, and corticosteroid injections offer a less invasive approach, but their efficacy varies substantially, and some methods may lead to complications like skin pigmentation changes or recurrence. This variability and the potential for scarring frequently enough leave patients feeling frustrated and with limited satisfactory treatment options.
Interviewer: The case study details the successful treatment of a pyogenic granuloma on the upper lip using oral thalidomide. What makes thalidomide a potential game-changer in this context? What is its mechanism of action, and why might it be effective where other treatments have failed?
Dr. Sharma: Thalidomide is a drug with a complex history,infamous for its devastating teratogenic effects. Though, it also possesses critically crucial anti-angiogenic and immunomodulatory properties.in the context of pyogenic granuloma, its effectiveness likely stems from several mechanisms. First, thalidomide inhibits angiogenesis, the formation of new blood vessels, by suppressing vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF). These growth factors play a crucial role in the proliferation of blood vessels associated with pyogenic granuloma. Second, thalidomide’s immunomodulatory affect helps to regulate the inflammatory response at the site of the lesion. Inflammation is also a primary component of pyogenic granuloma formation. By modulating the immune response and targeting angiogenesis, thalidomide effectively tackles underlying pathophysiological mechanisms.
Interviewer: The case study highlights the patient’s aesthetic concerns. How does thalidomide compare to other treatments in terms of cosmetic outcomes? What are the potential side effects and how are they managed?
Dr. sharma: This is a crucial point. Unlike surgical excision, thalidomide offers a way to treat pyogenic granulomas, especially in aesthetically sensitive areas, with minimal scarring. While surgical options
Thalidomide’s Unexpected Role: A New Hope for Pyogenic Granuloma Treatment?
is there a safe and effective way to treat pyogenic granuloma without scarring, especially on the face? A recent case study suggests a surprising answer lies in a drug with a controversial past: thalidomide.
Interviewer: Dr. Sharma, can you explain what pyogenic granuloma is for our readers, and why existing treatments sometimes fall short?
Dr. Sharma: Pyogenic granuloma,also known as lobular capillary hemangioma,is a common,benign vascular tumor. It presents as a rapidly growing, red nodule, frequently appearing on sun-exposed areas like the face, lips, and even the oral cavity. While not cancerous, its appearance can be distressing, particularly when located on visible parts of the body. Existing treatments often fall short because they balance efficacy with potential side effects and scarring. Surgical excision, while highly effective, can leave noticeable scars, especially on delicate areas like the lips.Non-surgical methods such as laser therapy, cryotherapy, and corticosteroid injections are less invasive, but thier effectiveness varies, and complications like skin discoloration or recurrence are possible. This variability and the potential for scarring leave many patients seeking improved treatment options.
Interviewer: The case study details the successful treatment of a pyogenic granuloma on the upper lip using oral thalidomide. What makes thalidomide a potential game-changer in this context? What is its mechanism of action, and why might it be effective where other treatments have failed?
Dr. Sharma: Thalidomide has a complex history, infamous for its teratogenic effects. However, it also possesses significant anti-angiogenic and immunomodulatory properties. Its effectiveness for pyogenic granuloma likely stems from a dual mechanism. First, thalidomide inhibits angiogenesis, the formation of new blood vessels, by targeting vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF). These growth factors are critical in the proliferation of the blood vessels characteristic of pyogenic granuloma. Secondly, thalidomide’s immunomodulatory effects help regulate the inflammatory response at the lesion site. Inflammation plays a key role in pyogenic granuloma advancement. By targeting both angiogenesis and inflammation, thalidomide addresses the underlying pathophysiological processes. This approach could explain its success where other treatments may have failed to adequately control both aspects of the disease.
Interviewer: The case study highlights the patient’s aesthetic concerns. How does thalidomide compare to other treatments in terms of cosmetic outcomes? what are the potential side effects and how are they managed?
Dr. Sharma: This is a critical advantage of thalidomide. Unlike surgical excision, it offers a less invasive approach with minimal scarring, making it particularly appealing for aesthetically sensitive areas. However, it’s vital to acknowledge potential side effects. The most significant is teratogenicity, making it unsuitable for pregnant women or those planning pregnancy. Peripheral neuropathy is another potential issue, although usually manageable. Other possible side effects, such as drowsiness or constipation, are generally mild. Close monitoring by medical professionals is essential to detect and manage any adverse effects promptly, allowing for adjustments to dosage or alternative treatment if necessary. The benefits in terms of cosmetic outcomes and reduced scarring may often outweigh these risks, especially in cases where other treatments have proved unsuccessful.
Interviewer: what are the next steps in research and clinical trials for thalidomide in the treatment of pyogenic granuloma?
Dr. Sharma: While this case study offers promising results, larger-scale, randomized controlled trials are necessary to confirm these findings and establish thalidomide’s efficacy and safety as a standard treatment. Further research is also needed to fully elucidate its mechanism of action in pyogenic granuloma and to identify patients who might benefit most from this treatment. These trials must also carefully monitor for and manage potential side effects to ensure the safety profile of thalidomide in this specific request is well-established.
Interviewer: What are your final thoughts on the potential of thalidomide in pyogenic granuloma treatment?
dr. Sharma: The successful outcome reported in this case study suggests thalidomide holds considerable promise as a novel therapeutic option for pyogenic granuloma, especially in areas where cosmetic concerns are paramount. However, it’s crucial to proceed cautiously and conduct further research to verify its safety and efficacy profile. Strict adherence to guidelines and careful patient monitoring are paramount to responsible therapeutic implementation. the potential for minimally invasive treatment with significant cosmetic improvements makes this an exciting area of ongoing dermatological research
What are your thoughts on this novel approach to pyogenic granuloma treatment? Share your comments below!