Noninvasive Treatments for Umbilical Granulomas

to the editor: In the article, “Double-Ligature: A Treatment for Pedunculated Umbilical Granulomas in Children,”¹ the authors describe a technique for extirpating umbilical granulomas; however, they seem to ignore the easily reversed root causes of these lesions. Granulomas usually form in reaction to a low-grade, superficial skin infection in periumbilical crevasses and flourish in the moist environment afforded by today's large “super-absorbent” diapers that often cover up the area. In minor cases (such as the one in the article¹), regular eversion by the caregivers of the umbilical stump with cotton-tipped swabs (demonstrated in Figure 1 of the article¹) allows cleansing with soap and water. This practice, combined with exposing the umbilical stump to the air (by rolling back or trimming the diaper top) will often stop low-grade infections and allow the granuloma to necrose in a matter of days. Application of a topical antibiotic cream (such as mupirocin applied three times daily) is another noninvasive adjuvant that treats the root cause of the granuloma and avoids any further procedural intervention.

IN REPLY: Thanks to Dr. Wooltorton for a nice and optimistic overview of noninvasive treatments for umbilical granulomas. I would add a resource¹ to his armamentarium that praises the curative effect of common salt on umbilical granuloma. This article¹ states that the high concentration of sodium ion in the area draws water out of the cells and results in shrinkage and necrosis of the wet granulomatous tissue.

However, contrary to Dr. Wooltorton's impression, we did not ignore the easily reversed root causes of these lesions; we mentioned them in the first two sentences of the abstract and the first part of the discussion of the article.² Dr. Wooltorton also implies that our technique is only pertinent for small umbilical granulomas such as in the case we presented in our article.² In reality, it is effective for large pedunculated granulomas and avoids a prolonged and usually unsuccessful trial of conservative treatment. In our experience of treating hundreds of umbilical granulomas in children, the conservative treatments described by Dr. Wooltorton are only effective in a limited group of patients. Most parents will find it difficult and unpleasant to evert the umbilical stump with cotton-tipped swabs, expose the umbilical stump to the air, and then wait for the stump to necrose and drop out.

Dr. Wooltorton's other suggestion of applying topical antibiotic cream daily is a common practice in our clinic; based on the results of this conservative treatment we decide whether to use the silver nitrate^3,4 or the double-ligature for the final treatment. The technique described in our article is simple, effective, and can be performed by most family physicians without fear or harm to the patient. Giving the mother the opportunity to hold the first ligature results in a positive feedback, because she feels like part of the therapeutic process. Her initial fear is quickly replaced by a sensation of gratification. Despite Dr. Wooltorton's observations, we still consider the double-ligature technique to be an attractive option for the treatment of pedunculated umbilical granulomas in children, when the conservative treatments fail.