What are the recommended management options for skin tags in an otherwise healthy adult, and how should treatment be modified for patients with diabetes, peripheral vascular disease, or on anticoagulants?

Management of Skin Tags

For otherwise healthy adults, skin tags should be removed by simple snip excision with scissors after topical cooling with ethyl chloride spray, which provides fast, painless anesthesia without the need for injectable local anesthetic. 1

Primary Treatment Options

Snip Excision (First-Line)

• Use ethyl chloride spray to freeze the skin tag for 3-5 seconds, then immediately excise the pedunculated lesion at its base with micro-scissors and micro-forceps 1
• This technique is significantly more comfortable than infiltrating local anesthesia into each individual lesion, particularly when treating multiple tags 1
• No suturing is required for pedunculated skin tags removed at the stalk 2, 3
• Apply pressure briefly with gauze if minor bleeding occurs, then cover with a simple adhesive bandage 1

Alternative Removal Methods

• Cryotherapy with liquid nitrogen can be used for smaller lesions (< 3mm base), applied for 10-15 seconds 2
• Electrodesiccation is effective but requires local anesthesia and may leave more noticeable scarring 2
• Trichloroacetic acid 5% can be applied carefully to the base of small skin tags, though this requires multiple applications 4
• Mechanical ligation devices that apply pressure to the base achieve 90% success for tags ≤1mm and 76% success for tags ≤2mm, with removal occurring over 3-6 days 5

Special Populations Requiring Modified Approach

Patients with Diabetes

• Screen for impaired glucose control before any procedure, as patients with >30 skin tags have a 52% prevalence of diabetes 6
• Ensure meticulous wound care with daily inspection, as diabetic patients have impaired healing and higher infection risk 7
• Use topical moisturizing creams around the excision site to prevent skin fissuring 7
• Avoid tight footwear or clothing that creates friction at excision sites on the body 7

Patients with Peripheral Vascular Disease

• Assess arterial perfusion to the affected area before excision; if pulses are diminished or absent, consider referral to vascular surgery 7
• Avoid excision on the lower extremities if ankle-brachial index is <0.5 or if there are signs of critical limb ischemia 7
• For tags on well-perfused areas (neck, axilla, trunk), proceed with standard snip excision 2, 1

Patients on Anticoagulation

• Do not routinely stop anticoagulation for simple skin tag removal, as the bleeding risk is minimal with proper technique 1
• Apply firm pressure for 3-5 minutes after excision if the patient is anticoagulated 1
• Consider using aluminum chloride 20% solution or silver nitrate sticks for hemostasis if needed 1
• Avoid excision only if INR >4.0 or if the patient is on dual antiplatelet therapy plus therapeutic anticoagulation; in such cases, coordinate with the prescribing physician 7

Post-Procedure Wound Care

• Keep the site clean and dry for 24 hours after excision 8
• Apply petrolatum-based ointment twice daily until the site is fully epithelialized (typically 5-7 days) 8, 9
• No antibiotics are needed unless clear signs of infection develop (expanding erythema >5cm, purulent discharge, fever >38.5°C) 8
• Clear to yellowish serous drainage is normal and does not indicate infection 8

Common Pitfalls to Avoid

• Do not infiltrate local anesthesia into every skin tag when treating multiple lesions—use ethyl chloride spray instead for patient comfort 1
• Do not assume all pedunculated lesions are benign—if a lesion is pigmented, rapidly growing, or has an irregular surface, perform excisional biopsy and send for histopathology 2, 3
• Do not underestimate diabetes risk in patients with >30 skin tags; these patients warrant glucose screening 6
• Do not delay wound assessment in diabetic or vascular disease patients—examine the site within 24-48 hours to detect early infection 7, 8