Pyogenic granuloma (PG), also known as lobular capillary hemangioma, is a benign vascular lesion that commonly arises following trauma, chronic irritation, or hormonal changes. It represents an exaggerated tissue response to minor injury or irritation, characterized by a proliferation of capillaries arranged in lobular aggregates within a fibromyxoid stroma [1]. The lesion typically presents as a red, friable nodule that bleeds easily, most frequently occurring on the skin, oral mucosa, and gingiva. Its occurrence in the nasal cavity—particularly on the septum is relatively rare, accounting for less than 7% of all pyogenic granulomas involving mucosal surfaces [2]. Nasal pyogenic granuloma often presents with recurrent epistaxis, nasal obstruction, and occasionally, localized pain or foreign body sensation. Predisposing factors include repeated trauma (such as nose picking or instrumentation), infection, pregnancy-related hormonal changes, and prolonged use of intranasal medications [3,4]. Clinically, these lesions are easily mistaken for other vascular or neoplastic lesions such as hemangioma, capillary malformation, or even malignancy, making accurate diagnosis essential. The pathogenesis of PG is attributed to an imbalance between angiogenic promoters and inhibitors, resulting in excessive vascular proliferation and granulation tissue formation [5]. Histologically, the lesion shows lobular aggregates of capillaries lined by flattened endothelial cells, surrounded by inflammatory infiltrate and fibrous tissue. Although the lesion is benign, its vascularity and tendency for recurrence make proper treatment imperative. Traditionally, surgical excision remains the mainstay of management, with techniques ranging from simple excision with cauterization to laser ablation or cryotherapy [6]. However, surgical procedures carry inherent risks of intraoperative bleeding, postoperative discomfort, and recurrence, particularly if the lesion base is inadequately cauterized. In recent years, the use of chemical cauterization with trichloroacetic acid (TCA) has emerged as a simple, safe, and minimally invasive alternative. TCA induces controlled coagulative necrosis, leading to lesion regression and mucosal re-epithelialization without the need for extensive surgery [7]. Several studies have demonstrated the successful use of topical TCA for small mucosal pyogenic granulomas, both as a standalone treatment and as an adjunct to other modalities. Chiriac et al. (2016) reported complete resolution of PG in pediatric patients using a combination of topical timolol and TCA, emphasizing its safety and practicality in outpatient settings [8]. Similarly, recent reviews advocate for TCA as a first-line option in small, well-defined lesions where surgical morbidity can be avoided [9]. Given the benign nature of the disease and the efficacy of non-surgical approaches, this case report aims to illustrate the successful management of septal pyogenic granuloma with topical TCA application, underscoring its role as a conservative, cost-effective, and minimally invasive therapeutic option.

A 32-year-old male presented to the otorhinolaryngology outpatient department with a two-week history of recurrent anterior nasal bleeding (epistaxis) from the right nostril, accompanied by mild nasal obstruction and a sensation of fullness in the nasal cavity. The patient reported that bleeding episodes were spontaneous, short-lasting, and self-limiting, but had become increasingly frequent over the preceding week. There was no associated history of nasal trauma, nose picking, intranasal drug use, chronic rhinosinusitis, or previous nasal surgery. He denied systemic conditions such as bleeding disorders, hypertension, or diabetes mellitus, and was not on any anticoagulant or nasal topical medication. There was no history of similar lesions elsewhere in the body. General physical examination was unremarkable, with stable vital signs and no pallor or lymphadenopathy. Local examination of the nose using anterior rhinoscopy revealed a reddish, friable, polypoidal mass approximately 0.8 × 0.6 cm in size, arising from the anterior part of the right nasal septum about 1.5 cm posterior to the vestibule. The lesion had a smooth surface, bled easily on touch, and was pedunculated with a narrow base. The surrounding septal mucosa appeared mildly congested but without ulceration. The opposite nasal cavity, middle meatus, and inferior turbinate were normal, and there was no septal deviation or perforation. Examination of the oral cavity, pharynx, and ears showed no abnormalities. Figure 1. Endoscopic View of Septal Pyogenic Granuloma Prior to Treatment Endoscopic image showing a reddish, friable, polypoidal lesion arising from the anterior part of the nasal septum. The lesion is characteristic of a septal pyogenic granuloma (lobular capillary hemangioma) prior to topical trichloroacetic acid (TCA) application (Figure 1). Based on the clinical presentation, a provisional diagnosis of septal pyogenic granuloma (lobular capillary hemangioma) was made. Routine investigations including complete blood count, bleeding time, clotting time, and prothrombin time were within normal limits. Because of the lesion’s small size and well-defined base, a non-surgical management plan using topical trichloroacetic acid (TCA) was chosen, with patient consent and counseling regarding possible local discomfort and need for follow-up applications. Treatment procedure: On Day 0, under local anesthesia and aseptic precautions, 10% TCA solution was applied topically over the entire surface of the lesion using a cotton-tipped applicator. The lesion immediately blanched, indicating effective chemical cauterization. The patient was advised to avoid nasal picking, forceful blowing, or topical irritants and was prescribed saline nasal drops for mucosal hydration. At the first follow-up (Day 7), mild crusting was observed at the site of application with no evidence of active bleeding or infection. The patient reported complete relief from epistaxis. At the second follow-up (Day 14), the lesion had shrunk considerably with a reduction in erythema and friability. Healthy granulation tissue was evident at the base, with partial re-epithelialization of the septal mucosa. A second thin coating of 10% TCA was applied to residual granulation tissue to ensure complete regression. By Day 28, the lesion had completely resolved, leaving behind smooth, intact mucosa with no crusting or scar formation. The patient remained symptom-free with patent nasal airway and no discomfort. A three-month follow-up examination demonstrated no recurrence, no septal perforation, and normal mucosal color and texture. The patient expressed satisfaction with the cosmetic and functional outcomes, and no secondary complications such as infection, pain, or delayed healing were encountered throughout the treatment course. Figure 2. Sequential Endoscopic Images Demonstrating Healing Response to Topical Trichloroacetic Acid (TCA) (Left to Right) • 1st week: Post-initial application of 10% TCA showing mild surface blanching and crusting with absence of active bleeding. • 2nd week: Marked reduction in lesion size and vascularity with early epithelial regeneration over the septal mucosa. • 4th week: Complete resolution of the granuloma with smooth, intact mucosa and healthy healing without scarring (Figure 2).

Pyogenic granuloma (PG), or lobular capillary hemangioma, though benign, poses significant clinical challenges when located in the nasal cavity because of its vascularity and propensity for bleeding. It typically arises in response to local trauma, mucosal irritation, or hormonal factors and is most commonly found on the gingiva, lips, or skin. Nasal involvement—particularly septal origin is relatively rare but has been well-documented in recent otolaryngology literature [10]. The lesion’s friability, rapid growth, and recurrent epistaxis make its management both urgent and delicate. The pathogenesis of PG is thought to involve dysregulated angiogenesis triggered by local irritation or trauma leading to capillary proliferation and lobular organization. Endothelial cells in these lesions express high levels of vascular endothelial growth factor (VEGF) and fibroblast growth factor (FGF), which contribute to the vascular overgrowth and inflammatory infiltration characteristic of PG [11]. The septal mucosa’s rich vascular network makes it particularly prone to such lesions after even minor trauma, such as digital manipulation, infection, or instrumentation. Clinically, patients often present with unilateral nasal obstruction and recurrent epistaxis, as observed in this case. The lesion typically appears as a well-circumscribed, reddish polypoidal mass that bleeds easily on touch. Though benign, untreated lesions may enlarge and interfere with nasal airflow or cause persistent bleeding, affecting quality of life [12]. Diagnosis of septal PG is primarily clinical but should always include differentiation from other vascular and neoplastic entities such as hemangioma, angiofibroma, capillary malformation, and granulomatous diseases. Endoscopic examination usually suffices, though imaging may be required in atypical or extensive lesions. Histopathological confirmation is classically reserved for excised specimens, but in small, typical lesions where conservative management is intended, chemical cauterization may be both diagnostic and therapeutic [13]. Surgical excision has long been the standard treatment for PG, often accompanied by cauterization or laser ablation to minimize recurrence [14]. However, surgery carries inherent drawbacks, including intraoperative bleeding, postoperative crusting, pain, and risk of septal perforation. The recurrence rate after incomplete excision is reported to be 5–15%, especially if the lesion’s base is inadequately treated [15]. Given these limitations, chemical cauterization using trichloroacetic acid (TCA) has gained traction as a minimally invasive alternative, particularly for smaller lesions. TCA acts by causing coagulative necrosis of the lesion through protein denaturation and dehydration of cells. This controlled destruction results in gradual sloughing of the granulomatous tissue, followed by re-epithelialization of the underlying mucosa [16]. Concentrations between 10% and 20% have been found effective and safe for mucosal application, producing excellent cosmetic and functional results without scarring or fibrosis [17]. In the present case, 10% TCA was applied under local anesthesia at weekly intervals, resulting in steady regression and complete resolution by the fourth week, with no recurrence after three months. This aligns with previous findings by Chiriac et al. (2016), who demonstrated successful treatment of pediatric pyogenic granulomas with combined topical timolol and TCA, achieving rapid healing and minimal complications [18]. Similarly, Al-Khtoum and Al-Masri [19] described chemical cauterization with TCA as a safe outpatient procedure with high patient acceptance. Khandpur and Reddy (2001) documented a comparable case of septal PG managed surgically but noted postoperative bleeding and prolonged healing time, underscoring the advantage of TCA in reducing procedural morbidity [12]. More recent reviews advocate for the inclusion of TCA as a first-line therapy for small, well-defined lesions (<1 cm) before resorting to surgical excision [20]. Advantages and Limitations The major benefits of TCA therapy include: • Minimally invasive and can be performed under local anesthesia in an outpatient setting. • Cost-effective and requires no surgical equipment or hospitalization. • Reduced risk of intraoperative bleeding or postoperative infection. • Excellent cosmetic outcome with minimal scarring. However, limitations include the need for repeated applications, risk of localized irritation if over-applied, and limited efficacy for larger or deeply seated lesions. Furthermore, in cases with diagnostic uncertainty or suspicion of malignancy, histopathological confirmation via surgical excision remains mandatory [21]. Other non-surgical options such as cryotherapy, laser photocoagulation, and topical beta-blockers (timolol) have been explored, with variable success. Laser techniques offer precision and hemostasis but are costly and require specialized equipment. Topical beta-blockers are effective for superficial lesions but less so in mucosal locations like the nasal cavity [22, 23]. In contrast, TCA offers a balanced combination of accessibility, simplicity, and proven efficacy for small septal PGs. The success of this case reinforces that topical trichloroacetic acid provides an effective, low-risk alternative for managing small septal pyogenic granulomas. For appropriately selected patients, it can serve as a first-line treatment that avoids surgical trauma, minimizes bleeding, and achieves complete healing. Regular follow-up is essential to monitor for recurrence, though rates appear negligible when the lesion is fully cauterized.

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