Skin Tag Removal

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Skin Tag Removal

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Introduction

Skin tags, or acrochordons, are 1- to 2-mm skin growths commonly encountered on the neck, axilla, groin, or inframammary areas. The lesions develop on skin surfaces that rub together or that chronically rub against clothing. Skin tags are histologically classified as fibromas, with hyperplastic epidermis connected to the skin on a connective tissue stalk. At least one fourth of all adults exhibit skin tags, with one half of these occurring in the axilla. The lesions usually begin as tiny, flesh-colored or light brown excrescences. As the lesions enlarge, they can rub on clothing and commonly develop added pigmentation. Not all polypoid lesions are skin tags; nevi, angiomas, and even melanomas can appear polypoid. 
Skin tags increase in frequency from the second to fifth decade but generally do not increase significantly in number until after 50 years of age. There is a familial tendency for development of skin tags. Perianal skin tags may be associated with Crohn disease. Skin tags also may increase during the second trimester of pregnancy and may regress during the postpartum period. An association with type 2 diabetes mellitus also has been observed. Skin tags in adults historically have been associated with the presence of adenomatous colonic polyps, but studies in the primary care setting have failed to confirm such an association. 
Fibroepitheliomatous polyps are larger, similar lesions commonly found on the trunk, eyelids, neck, and perineum. Fibroepitheliomatous polyps often have a baglike end on a narrow stalk and can grow quite large. Both acrochordons and fibroepitheliomatous polyps can be easily removed with the office techniques described here. Commonly used options for removal of skin tags include scissoring, sharp excision, ligature strangulation, electrosurgical destruction, or a combination of treatment modalities, including chemical or electrocauterization of the wound. These methods may employ local anesthesia, especially if the lesion is broad-based. 
Electrosurgical excision is commonly employed for skin tags. The technique is hemostatic and is beneficial for removal of lesions, especially in noncosmetic areas (e.g., groin, axilla) or on the eyelids, where chemical hemostatic agents usually are avoided. The downside of electrosurgery for skin tags is the time required for equipment setup, the odor created during the procedure, and the need for anesthesia when using this technique. Cryosurgery avoids the need for anesthesia. However, the time required to perform cryosurgical destruction is greater than with other methods, and this method may be more painful. 
Scissor excision is considered by many authorities to be the optimal removal technique for skin tags. Most small tags can be removed without the need for anesthesia, and scissor removal permits rapid removal of numerous lesions. It is not uncommon to remove 100 or more lesions at a single session, although some insurance companies cap payment at 45 to 65 tags per session. Because residual scarring depends on the depth of dermal injury, scarring can be minimized with scissor removal. Histologic assessment is offered to patients but may not be necessary if the experienced clinician removes small, characteristic tags. Application of antibiotic ointment usually promotes rapid (moist) healing of the site. 

Equipment

  • Required instruments depend on method selected for removal. If scissors removal is chosen, a pair of new, sharp, curved iris scissors should be available. If cryosurgery or electrosurgical excision is performed, see Cryosurgery of the Skin and Radiosurgical Skin Surgery (LEEP) for descriptions of the needed equipment. Skin preparation recommendations appear in Appendix E.

Indications

  • Removal of superficial, polypoid growths on characteristic surfaces of the neck, groin, and eyelids

Contraindications

  • Pigmented skin lesions (especially flat lesions) generally should not be destroyed because of the possibility of the lesion being a melanoma. If there is any concern about an unusual appearance of a lesion or confusion about whether a lesion is a skin tag, the lesion should have a full-thickness biopsy and histologic assessment.

  • Fibroepitheliomas (often called large skin tags) often have a larger arterial supply that will require bleeding control and possibly suture closure.

The Procedure

Scissors Removal

Step 1
Most lesions can be rapidly removed without anesthetic. A simple anesthesia is chilling the skin with an ice cube before excising the lesion. The ice cube can be advanced to the next lesion while cutting the current lesion for efficient removal of multiple lesions. 
Alternatively, when lesions are large or have a wide base (>2 mm), consider administering lidocaine cream or a small bleb of 1% lidocaine with epinephrine beneath the lesion. 
Figure 1
Figure 1
Picture courtesy of Dr. Jeff German. 
Step 2
Use the nondominant hand to stretch skin to allow quicker removal with less pain. The nondominant thumb and index finger should forcefully stretch the skin surface to provide countertraction and to stretch pain fibers. 
  • PITFALL: It is easier to remove tags that are elevated with forceps. However, forceps pull up normal tissue beneath the tag, producing more scarring because of the deeper dermal injury. Dark-skinned individuals develop much more hypopigmentation and even keloid formation at skin tag removal sites when forceps are used. Avoid the use of forceps and learn to elevate the lesions in the blades of the scissors.

Step 3
Use sharp, new, iris scissors. The tips of iris scissors are not best for cutting. Place the lesion into the blades of the scissors, at least one fourth of the way back from the tips. Wedge the closing blades of the scissors beneath the lesion, making sure no surrounding skin is caught between the blades. 
  • PITFALL: Straight iris scissors are often preferred by experienced clinicians, but may inadvertently pull surrounding tissue into the blades of the scissors. Curved iris scissors are easier to use for novice practitioners and may minimize the risk of removing excessive tissue.

Step 4
Rapidly cut the skin tag free. Apply Monsel solution (i.e., ferric subsulfate) or aluminum chloride solution to the wound base for hemostasis. 
  • PEARL: Talk to the patient during the procedure because “verbal anesthesia” usually helps. For instance, tell the patient to take a deep breath as the skin tag is cut.

  • PEARL: Silver nitrate provides good hemostasis in this setting but runs the risk of depositing black silver salts under the skin (tattooing), which may later be confused as a developing melanoma.

Electrosurgical Removal

Step 1
Alternatively, the base of the lesion can be anesthetized, and an electrosurgical loop is placed over the lesion. Grasp the lesion with forceps, apply current to the loop, and pass the loop through the base of the lesion. Feather the base if any of the lesion remains. See Radiosurgical Skin Surgery (LEEP)
  • PITFALL: Avoid full-thickness or deep cuts or burns, because greater scarring is produced.

Cryosurgical Removal

Step 1
Alternatively, the skin tag may be frozen. Pour liquid nitrogen into a disposable polystyrene cup. Cover the handle of the forceps with a folded 4×4-inch gauze to protect the fingers. Then dip the forceps into the liquid nitrogen until it becomes frosted. Pinch the lesion between the tips of the cold forceps until it turns frosty white. Keep the forceps on for an additional 15 seconds and repeat the process. 
  • PEARL: Benign lesions will fall off within 1 week and usually heal without problems.

  • PITFALL: This method is slow and primarily used when only a few lesions are present.

    Step 1

    Picture courtesy of Dr. Russell Roberts.

    Step 1

    Picture courtesy of Dr. Russell Roberts.

Complications

  • Bleeding

  • Infection

  • Scarring

Pediatric Considerations

Skin tags are rare in childhood and, when found, may indicate the presence of other disorders such as nevoid basal cell carcinoma syndrome. Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit or lie still during even mildly painful procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. 

Postprocedure Instructions

Instruct the patient to gently wash the area the next day. Have the patient clean and dry the area well after washing, and use a small amount of antibiotic ointment to promote moist healing. 

Coding Information and Supply Sources

Bibliography

Bennett RG. Fundamentals of Cutaneous Surgery. St. Louis: Mosby;  1988:692.
Chiritescu E, Maloney ME. Acrochordons as a presenting sign of nevoid basal cell carcinoma syndrome. J Am Acad Dermatol .  2001;44:789–794. [View Abstract]
Coleman WP, Hanke CW, Alt TH, et al. Cosmetic Surgery of the Skin: Principles and Techniques. St. Louis: Mosby;  1997.
Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 3rd ed. St. Louis: Mosby;  1996.
Kuwahara RT, Huber JD, Ray SH. Surgical pearl: forceps method for freezing benign lesions. J Am Acad Dermatol .  2000;43:306–307. [View Abstract]
Kwan TH, Mihm MC. The skin. In: Robbins SL, Cotran RS, eds. Pathologic Basis of Disease. 2nd ed. Philadelphia: WB Saunders;  1979:1417–1461.
Parry EL. Management of epidermal tumors. In: Wheeland RG. Cutaneous Surgery. Philadelphia: WB Saunders;  1994:683–687.
Usatine RP, Moy RL, Tobnick EL, et al. Skin Surgery: A Practical Guide. St. Louis: Mosby;  1998.
Zuber TJ. The illustrated manuals and videotapes of soft-tissue surgery techniques. Kansas City: American Academy of Family Physicians; 1998.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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