Skin Tags (Acrochordons): Definition and Treatment
Skin tags are benign, pedunculated skin lesions that should generally be left untreated unless symptomatic or causing cosmetic concern, with simple snip excision being the preferred removal method for most cases.
What Are Acrochordons?
Acrochordons (skin tags) are common benign neoplasms consisting of soft, skin-colored or hyperpigmented pedunculated projections that predominantly occur in intertriginous areas including the neck, axillae, groin, and eyelids 1, 2. These lesions develop through friction-induced mechanisms, particularly in skin folds 1. While primarily a cosmetic concern, they are associated with metabolic conditions including obesity, diabetes mellitus, and dyslipidemia 3, 4.
Treatment Algorithm
When NOT to Treat
Excision of typical skin tags in certain contexts is contraindicated and can lead to severe complications:
- In Crohn's disease patients, excision of Crohn's-associated skin tags is NOT recommended due to high rates of postoperative complications including poor wound healing and subsequent proctectomy 5
- Asymptomatic skin tags without diagnostic uncertainty require no intervention 5
When to Treat
Treatment is indicated for:
- Cosmetic concerns expressed by the patient 1, 2
- Symptomatic lesions (irritation, bleeding, pain) 2
- Diagnostic uncertainty requiring histological confirmation 6
Treatment Options by Clinical Scenario
For isolated, small skin tags (<2mm base):
- Snip excision with micro-scissors and micro-forceps is the gold standard 2
- Ethyl chloride spray provides fast, painless topical anesthesia immediately before excision 2
- Cryotherapy is an effective alternative once diagnosis is confirmed 6, 1
- Electrodesiccation can be used for individual lesions 1
For multiple widespread skin tags:
- Mechanical occlusion devices achieve 90% success for lesions up to 1mm base diameter and 76% success for lesions up to 2mm, with removal occurring within 3-6 days 7
- Sequential snip excision with ethyl chloride spray anesthesia for each lesion 2
For lesions with diagnostic uncertainty:
- Excision with histological examination is mandatory to exclude malignancy 6
- Document location and size on body diagram before intervention 6
Critical Management Considerations
Avoid infiltrative local anesthesia for routine skin tag removal - this causes unnecessary pain compared to ethyl chloride spray or simple snip excision 2. Patients who previously underwent conventional anesthetic techniques report significantly greater comfort with ethyl chloride-based procedures 2.
Screen for metabolic syndrome - patients with skin tags have 1.89 times greater risk of developing diabetes mellitus compared to those without skin tags 4. There is significant association with elevated triglycerides, LDL, VLDL cholesterol, and leptin levels 3. Consider checking fasting glucose, HbA1c, and lipid profile, particularly in patients with multiple skin tags 3, 4.
Distinguish from Crohn's disease-associated skin tags - always obtain gastrointestinal history before excision, as surgical intervention in Crohn's patients carries prohibitive complication rates 5.
Common Pitfalls
- Performing biopsy or excision on Crohn's disease-associated perianal skin tags - this leads to poor wound healing and potential proctectomy 5
- Using painful infiltrative anesthesia when topical ethyl chloride spray provides adequate anesthesia 2
- Failing to screen for diabetes mellitus and metabolic syndrome in patients with multiple skin tags 3, 4
- Treating asymptomatic lesions without patient-driven cosmetic concerns 1, 2