Skin Tags

Etiology

Skin tags have found to be associated with[3][4]:

1. Abnormal lipid profile
2. Type 2 diabetes
3. Cardiovascular disease 
4. Obesity 
5. Genetic factors 

Frequent irritation of the skin has been implicated as a cause, chiefly in individuals who are obese. Experts believe that acrochordons are simply due to the normal aging process of the skin and the subsequent loss of elasticity. Hormonal imbalances may potentiate the development of skin tags (e.g., elevated levels of the female sex hormones, progesterone, and estrogen, elevated levels of human growth hormone in acromegaly). Both alpha tissue growth factor and epidermal growth factor (EGF) may also be risk or trigger factors for skin tags. While infective etiologies have not been reported to be a cause of acrochordons, there are anecdotal reports of some viruses that may be the cause. The human papillomavirus (HPV): in many studies conducted on various patients, researchers have observed a correlation between the infection and skin tags. Finally, there has also been an observed association with type 2 diabetes mellitus and skin tags in many studies.

Epidemiology

Frequency

Acrochordons have a reported incidence of 50 to 60% in the general population overall.[4]

Sex

Prevalence in males and females has been reported to be equal.

Age

Once a skin tag has developed, it may increase in size or number with advancing age. By the fifth to sixth decade, close to two-thirds of individuals may develop acrochordons, which usually remain until the end of life.

Pathophysiology

The histopathology of the skin tag will reveal an attenuated epidermis, a flattened basal cell layer, and often increased pigmentation. The extra mass is composed of loose fibrous tissue. The mass is connected to the skin by a narrow and thin pedicle. However, there are significant variations in this attachment. Melanocytic proliferation and nevus cells are not present in the majority of cases, and most such lesions probably fall into the seborrheic keratosis spectrum. However, there is an overlap with certain other conditions like melanocytic nevi and neurofibromas. It appears that some skin tags may be the last remnants of a pre-existing melanocytic nevus.

Histopathology

Histology of the pedunculated skin lesion will reveal the presence of mild hyperkeratotic epidermis, containing blood vessels of various sizes in the dermal stroma. Acrochordons are usually also identified by their flattened, acanthotic, presentation, or will have a 'flowery' pattern like epithelium. The dermal layer usually has loosely arranged collagen fibers along with lymphatic vessels and dilated capillaries. Appendages are generally not seen in the classic lesion.[5]

History and Physical

Presentation: The lesions are usually pedunculated on a thin stalk. The length of stalk varies, and the lesions are about 0.5 to 2.5 mm in diameter. Skin tags often appear round and soft and are easy to diagnose simply by a visual examination. Smaller lesions may be visible with the use of a magnifying glass. The skin tag may be the same color as the skin or be hyperpigmented; in general, the latter is more common. Skin tags are most on the side of the neck, axillary region, and groin.[6]

Acrochordons have the following general descriptions:

• Small skin tags:- furrowed papules of approximately 1 to 2 mm in width and height, most frequently appearing on the neck and the axillae

• Mid-sized skin tags:- solo or multiple filiform skin tags that are roughly 5 mm long and 2 mm wide, occurring at other sites on the body

• Large-sized skin tags: - pedunculated lesions that may demonstrate a baglike, nevoid, baglike appearance, or soft fibromas usually located on the lower part of the body (groin)

Giant skin tags attract considerable attention, as they are known to produce significant discomfort for patients when located in the axillae and genital regions.

Evaluation

The patient should undergo evaluation for diabetes mellitus by ordering levels of A1c, fasting blood glucose, and postprandial blood glucose. Additionally, the patient's lipid profile should requires monitoring. The clinician should record the patient's BMI should and serially follow it.

Treatment / Management

There are several treatments of skin tags, and all require removal of the lesion. Today, the use of radiocautery in the office is the most commonly performed procedure. Other methods of removal include the following:

• Snip excision
• Cautery 
• Cryosurgery 

Smaller skin tags are also removed using the nanosecond Q-switched Nd: Yag or the CO2 laser. Some patients may require an injection/topical application of a local anesthetic to minimize the pain. After excising the skin tag, the tiny wound usually heals on its own.

In most cases, the treatment almost always consists of excision and removal using radio cautery, snip excision, or cryosurgery. However, most specialists prefer radio cautery due to its ease of use and precision.

Risks associated with skin tag removal

Skin tag removal is primarily a low-risk clinic procedure. However, the lesion often freely bleeds when removed, requiring pressure and monitoring during the procedure. On occasion, coagulation with silver nitrate or electrocautery is necessary.

In rare cases, the patient may experience heavy bleeding or the development of an aberrant infection after the surgery. The clinician can mitigate the risk for complications by taking a proper history of any prescription or over-the-counter medications the patient might be taking since some drugs, and herbal supplements can alter the bleeding and clotting times.

It is also crucial that the patient follows proper instructions on how to care for the area of skin tag removal; this will reduce the risk of infection after the procedure. The patient must never try to remove the skin tags at home. Without proper technique and a sterile environment, the risk for excessive bleeding and infection increases.

Differential Diagnosis

• Dermatologic manifestations of neurofibromatosis type 1, in some instances, resemble skin tags.

• Genital warts sometimes also resemble skin tags.

• Melanocytic nevi resemble hyperpigmented skin tags.

• Nongenital warts resemble skin-colored skin tags.

• Premalignant fibroepithelial tumor (Pinkus tumor) is rare but could be a consideration.

• Seborrheic keratosis is again a rare but possible differential diagnosis.

Surgical Oncology

Skin tags are usually benign, and after excision, the histopathology reports confirm the same in most cases.

Prognosis

The skin tag, if left unchecked, may increase in size due to the constant friction with clothing and skin fold. However, the histological features remain the same, and these lesions have a very low or no risk of malignancy.

Complications

A skin tag may twist on its pedicle and become inflamed; in many cases, obese individuals exhibit an increased risk of inflammation.[7]

Complications of Removal

• Scarring can occur with improper removal of the skin tag.
• Sometimes normal skin tissue can be removed, which can lead to changes in cosmesis. Thus, the need to seek assistance from an experienced clinician.
• Mild irritation and even irritant dermatitis may occur in the area where the skin tag removal took place.
• Rarely, a neuroma may result if a nerve growth in the skin tag gets cut, resulting in chronic pain for some weeks or even months.