Management of Perianal Skin Tags in Children
Perianal skin tags in children should NOT be surgically excised unless absolutely necessary, as they are typically benign and asymptomatic, and surgical removal carries significant risks of poor wound healing and chronic complications.
Initial Assessment and Differential Diagnosis
The first priority is to determine whether these are simple benign skin tags or manifestations of underlying disease:
Rule out Crohn's disease by assessing for inflammatory bowel disease symptoms including chronic diarrhea, weight loss, abdominal pain, and other gastrointestinal complaints, as perianal skin tags occur in 35% of pediatric Crohn's patients and may be the presenting sign 1
Exclude perianal streptococcal dermatitis, which is the most common infectious perianal disease in children (16% prevalence in one series), presenting with perianal erythema, pruritus, and painful defecation; diagnosis requires perianal swab culture 2
Consider infantile perianal pyramidal protrusion, a benign condition predominantly affecting prepubertal girls that can be mistaken for skin tags or condyloma, characterized by a pyramid-shaped protrusion anterior to the anus 3
Assess for lichen sclerosus, particularly in girls, which causes perianal involvement in 30% of cases and may present with skin changes that could be confused with tags 4
Conservative Management Approach
For isolated benign perianal skin tags without underlying pathology, observation is the recommended strategy:
Do NOT excise Crohn's disease-associated skin tags, as a high rate of postoperative complications including poor wound healing and subsequent proctectomy has been reported following excision 4
Avoid surgical intervention for concomitant perianal skin tags in Crohn's disease, as this can lead to chronic non-healing ulcers 4
Provide meticulous perineal hygiene care to prevent irritation and secondary infection 1
Reassure parents that most perianal skin tags in children are benign and asymptomatic 5
When Surgical Excision May Be Considered
Excision should only be performed in highly selected cases:
Cosmetic concerns in the absence of Crohn's disease or other inflammatory conditions, where the lesion is truly isolated and benign 6
Symptomatic lesions causing significant discomfort, bleeding, or hygiene difficulties that cannot be managed conservatively
Diagnostic uncertainty requiring histopathologic confirmation when malignancy or other pathology cannot be excluded clinically 5
Treatment of Underlying Conditions
If perianal skin tags are secondary to Crohn's disease:
Treat the underlying inflammatory bowel disease medically with appropriate immunosuppressive therapy 1
Consider metronidazole therapy, which showed amelioration in 72% (38/53) of pediatric Crohn's patients with perianal disease 1
Maintain conservative management with meticulous perineal care as the cornerstone of treatment 1
Critical Pitfalls to Avoid
Do not mistake infantile perianal pyramidal protrusion for condyloma acuminata or signs of sexual abuse, as this leads to unnecessary investigation and psychological trauma; recognition requires awareness of the characteristic presentation in prepubertal girls 3
Do not perform surgical excision on Crohn's-associated skin tags, as this consistently results in poor outcomes including non-healing wounds and potential need for proctectomy 4
Do not overlook perianal streptococcal dermatitis, which requires systemic antibiotic treatment (typically 10-14 days) and cures all patients when properly diagnosed 2