Table Salt Method Following Cryotherapy for Recurrent Pyogenic Granuloma on the Fingertip

Practice Gap

Pyogenic granulomas (PGs) are benign endothelial tumors of the skin or mucosae that frequently become ulcerated and may cause patients substantial discomfort or distress due to rapid enlargement and bleeding.¹ These lesions often manifest as solitary red papules or polyps following localized trauma or irritation. They can grow up to 1 cm over a few weeks to several months. Pyogenic granulomas can develop at any age, but they most commonly are seen in children and young adults, with a slight male predominance.^1,2 The differential diagnosis for PG includes amelanotic melanoma, bacillary angiomatosis, Kaposi sarcoma, glomus tumor, infantile hemangioma, and irritated melanocytic nevus.¹ Histologically, PGs are well-circumscribed exophytic or pedunculated proliferations of small capillaries that often are arranged in a lobular pattern. Early lesions show packed endothelial cells, while advanced lesions display more ectatic vessels, erosion, and crusting.³ The term pyogenic granuloma is a misnomer, as these lesions display neither an infectious etiology nor granulomatous tissue on dermatopathologic examination.⁴ A more accurate clinical description for this lesion is a lobular capillary hemangioma.

Numerous surgical and laser techniques have been used to treat PGs, with varying degrees of success. Treatment often consists of either shave excision followed by electrosurgery at the base or full excision with suturing under local anesthesia for patients who can tolerate anesthetic injections.¹ Pulsed dye laser has been proven to be a safe alternative treatment option, particularly in children who otherwise would not tolerate surgical procedures.⁵ Topical beta-blockers, silver nitrate cauterization, sclerotherapy, and liquid nitrogen all have been used as alternative treatment methods.¹

Pyogenic granulomas often recur after first-line treatments, and patients may hesitate to try more invasive techniques when the first choice has failed. Children may not be amenable to any of these curative techniques, as they may not tolerate the pain associated with lidocaine injection and/or have a fear of needles or surgical intervention; even adults may be reluctant to have a procedure they perceive as painful. We present a less invasive technique for treatment of recurrent PGs using table salt and cryotherapy.

The Technique

A 51-year-old woman with no notable medical history presented to the emergency department for evaluation of a black dot on the pulp of the right third fingertip of 1 week’s duration. The patient reported rapid progression to an ulcerated red nodule with associated bleeding for the past 3 days (Figure 1). Direct pressure temporarily alleviated the bleeding, but it started again upon cessation of pressure. She denied any preceding trauma to the area or any associated systemic symptoms such as fever, chills, nausea, or vomiting.

The inpatient dermatology team recommended that the patient be discharged following silver nitrate cautery, with a referral sent to outpatient dermatology; however, the patient returned to the dermatology clinic 4 days later, at which time physical examination revealed a well-circumscribed, 5-mm, bright-red, erosive papule with overlying hemorrhagic crust that was not actively bleeding, as well as fissuring of the surrounding skin. The entire lesion was removed using tangential excision followed by electrodesiccation at the base. Pathology revealed small capillaries arranged in a lobular pattern, confirming the diagnosis of PG. At a 2-week follow-up visit, the patient noted that the lesion had recurred within 24 hours after the procedure and was larger (Figure 2). At this visit, management was switched to a single treatment of cryotherapy (3 cycles for 5 seconds per cycle), and the table salt method was recommended based on a literature review for alternative nonpainful approaches for PG.^6-11 We used this technique in our patient as an adjuvant to cryotherapy with the goal of reducing the need for additional painful procedures, but table salt also can be used as a standalone treatment without prior cryotherapy.

The patient was instructed to apply table salt to the lesion once daily for 2 weeks by pressing the lesion into a small amount of salt placed on a clean plate and then applying an occlusive dressing such as surgical or paper tape. She also was advised to apply petroleum jelly around the periphery of the lesion prior to salt application to protect the unaffected skin from irritation. Complete resolution of the lesion was seen when the patient followed up 2 weeks later (Figure 3). At the most recent follow-up 2 months after treatment, no further recurrence of the PG was reported.

Practice Implication

Pyogenic granulomas can be distressing for both patients and providers because they are cosmetically bothersome and prone to spontaneous bleeding. Various medical and surgical options exist to treat PGs, but there is no clear consensus on a superior modality. A 2019 study by Daruwalla and Dhurat⁶ highlighted a less invasive treatment option for PGs using table salt applied once daily for 2 weeks under an occlusive dressing with good outcomes and without involving other treatments such as cryotherapy. Several other case reports have endorsed this approach, adding anecdotal evidence for its utility.^7-11 Topical sodium chloride may treat PGs primarily through osmotic desiccation, drawing water out of the lesion and leading to endothelial cell shrinkage and collapse of its capillary network. This hyperosmolar environment also may induce microvascular thrombosis and ischemia, promoting lesion necrosis. Additionally, repeated application creates a dry, mildly irritative surface that may suppress angiogenesis and encourage regression of the vascular proliferation.

Consider topical application of table salt for treatment of PGs in certain subsets of patients; for example, patients who are not amenable to surgery or are too young for advanced surgical techniques may be good candidates for this method, as it does not require anesthetic injections and generally is pain free. Patients with resistant or recurrent PGs that did not respond to first-line treatments such as cryotherapy, tangential excision, or electrodesiccation may be more amenable to a less invasive secondary approach.

Importantly, we used a dual-therapy approach in our patient, initially using a single application of cryotherapy followed by the table salt method once daily for 2 weeks. This imposes limitations on the generalizability of table salt as a standalone approach for treating PGs. In this case, we did not have prior practical experience using table salt for this condition and only had small reports to justify its use. As a result, we attempted a more traditional treatment initially (cryotherapy) to avoid potential delays in resolution. The clinicians recommended table salt as an adjuvant prior to seeing the cryotherapy results because this treatment was benign and offered potential additive results, and therefore waiting was not necessary. However, various other cases have reported similar success using table salt as monotherapy.^6-9,11 Patients should be advised of potential mild adverse events, such as irritation to the surrounding skin. Higher-level evidence studies are required to further vet the utility of the table salt method for treatment of PGs.