You are reviewing a baby in the clinic when mum mentions incidentally that she’s noticed his umbilicus looks a bit ‘funny’ and bleeds occasionally. You pull up his top and have a look...
What is an umbilical granuloma?
This is an umbilical granuloma, and it’s pretty common. A Japanese case series reported an incidence of 5.9% (in 6680 neonates. It’s caused by a mild infection and usually appears shortly after cord separation (although there can be a delay of a few weeks).
It looks like pink or red soft tissue at the site of the umbilicus.
Sometimes, they can bleed when they rub against the nappy or clothing but otherwise can be asymptomatic.
How should I treat an umbilical granuloma?
There are a number of potential treatment options.
Salt is most people’s preferred option. This involves the parents applying a pinch of table salt to the granuloma and covering it with gauze. They leave it on for 20-30 minutes and then rinse it off gently using gauze soaked in water. This is repeated a couple of times a day for a couple of days. There is a good guide here.
A scoping review conducted in September 2022, covering 24 articles (including systematic reviews, randomized controlled trials, and various studies), concluded that the topical application of common salt is a safe, effective, and inexpensive remedy for umbilical granuloma. This treatment showed a success rate of 93.91% (1033/1100 cases). No complications or recurrences were reported. This review highlights the simplicity and efficacy of common salt application and notes the need for more randomized controlled trials in this area
Here is the typical progression with salt treatment.
Using silver nitrate
Silver nitrate is also an option, although it relies on the person applying it avoiding the surrounding skin. Silver nitrate rarely causes burns.
Putting petroleum jelly, like Vaseline, on the skin around the umbilicus can help protect it. The vaseline should be applied three times a day.
A systematic review of randomised controlled trials (RCTs) conducted in September 2020, covering various topical treatments for UG, included studies on topical steroids. This review analyzed eleven RCTs involving 890 cases. It found that topical steroids achieved resolution in over 90% of cases. However, the review noted that the risk of bias was high.
An analysis comparing topical steroids for treating UG to silver nitrate therapy found that topical steroids, such as clobetasol propionate 0.05% and betamethasone valerate 0.12%, were effective treatment options. The authors highlighted that topical steroids might have a longer healing time compared to silver nitrate but are associated with a better safety profile. While the overall risk of treatment failure was similar between topical steroids and silver nitrate, the non-inferiority of topical steroids had not been conclusively established.
There is a risk that using potent steroids like clobetasol and betamethasone for 3-4 weeks on highly vascular granulomatous tissue might lead to systemic absorption and potential suppression of the hypothalamic-pituitary-adrenal (HPA) axis. Local side effects, such as skin hypopigmentation and atrophy, can also occur. While no major adverse effects were reported in the RCTs involving topical steroids, the impact on the HPA axis was not fully analyzed. Therefore, it’s suggested that potent steroids should be used cautiously, especially when simpler and as effective treatments like common salt are available.
Is that the same for all umbilical granulomas?
This one is quite large, so it’s likely to require silver nitrate.
Smaller ones can be left and will generally resolve spontaneously. Some people recommend applying salt to the smaller granulomas – place it on a swab and hold it to the granuloma for 5-10 mins.
Healing rates varied significantly among treatment modalities: 91% for silver nitrate, 97.7% for betamethasone, 60% for ethanol disinfection, and 88% for ligation.
Is there anything else I should look out for?
Look out for urine or stool discharging from the umbilicus (suggesting uracho- or vitello-intestinal duct abnormalities). They are not very common.
Occasionally, granulomas do not go away with silver nitrate and may need a surgical referral.
Banerjee, A., Munghate, G., Bodhanwala, M. and Bendre, P.S., 2023. Treatment of umbilical granuloma in infants with topical application of common salt: A scoping review. Journal of Pediatric Surgery.
Iijima, S., 2023. Umbilical Granuloma: Frequency, Associated Factors, 10-Year Treatment Trends, and Effectiveness at a Single Hospital in Japan. Journal of Clinical Medicine, 12(18), p.6104.
Jois, R.S. and Rao, S., 2021. Management of umbilical granuloma in infants: A systematic review of randomised controlled trials. Australian Journal of General Practice, 50(8), pp.589-594.
Sandinirwan, I., Leo, H., Kahuna, H. and Karina, P.P., 2021. Treating umbilical granuloma with topical corticosteroid: A systematic review and meta-analysis. Journal of Research in Clinical Medicine, 9(1), pp.31-31.
Image from Mike Cadogan.