Acrochordon

Acrochordon (commonly known as skin tag) is a small, single pedunculated, painless benign polypous formation of the skin that most commonly develops in skin folds, but also other areas. It is seen in adults and the elderly, more commonly among females, and the presence of acrochordon has been associated with diabetes mellitus. It is usually asymptomatic, and surgical treatment is the method of choice.

The disease is related to the following processes:  neoplastic and has an incidence of about  14 / 100.000.

Presentation

The clinical presentation involves the appearance of small, elevated (pedunculated), either skin-colored or brown painless papules that develop either as single lesions, or may occur as multiple lesions in the same site. Their size can range from one or two millimeters, up to a centimeter (in which case it is somewhat mobile), and they are most commonly identified in the intertriginous areas, such as the groins, the axillae, as well as the neck region, and sometimes the eyelids can be a site of occurrence. They are asymptomatic but can become irritating and painful if exposed to mechanical trauma, such as skin rubbing or scratching, which may lead to the development of crusts and hemorrhage.

Workup

Diagnosis of acrochordon is made during clinical examination, by inspection of the skin lesion. Typical appearance of small, pedunculated painless lesions is highly suggestive of acrochordons. However, if the appearance is not characteristic, including a more firm structure, different color, surrounding erythematous skin, or the appearance of some other signs that do not normally accompany acrochordons, biopsy of the lesion is indicated, to determine the etiology of the lesion. Histological examination of the acrochordon reveals a very thin epidermis, and loose fibrous connective tissue in its core, sometimes with adipose tissue, without the presence of malignant cells. It is important to distinguish acrochordons from other skin lesions such as warts, or melanocytic nevi, which can be pedunculated as well.

Treatment

Treatment is indicated primarily for aesthetic reasons, as acrochordons present no harm to the patient, unless a malignant etiology is revealed, and comprises different surgical techniques:

  • Simple snipping - smaller, pedunculated acrochordons can be removed by snipping with serrated blade scissors, with prior application of aluminum chloride or ethyl chloride to minimize bleeding [11].
  • Electrodesiccation - for somewhat larger lesions, removal is performed through curettage (scraping of the lesion up to the dermis) followed by electrodesiccation - burning of the lesion using an electric current.
  • Cryosurgery - removal of acrochordons through the application of liquid nitrogen, which induces freezing of tissues, and subsequent removal is also a choice of therapy [12].

Prognosis

Acrochordons are benign tumors of the skin, and they carry a good prognosis, as their malignant potential is very rare, but biopsy samples have revealed basal or squamous cell carcinomas in patients. Because of these facts, they should be handled with caution, and if the lesions appear uncharacteristic, or have an unusual shape or appearance, a skin biopsy should be performed to exclude a potentially malignant skin tumor. They are easily removed, and pose no threat to the patient.

Etiology

The etiology of acrochordons is not fully understood, but it seems that frequent irritation of the skin, particularly in obese individuals, in whom these polypoid formations are commonly seen, is one of the factors involved, which is supported by the fact that it most commonly occurs in intertriginous areas. Other factors have been suggested, such as hormone disbalance (such as in pregnancy, when lesions increase both in size and number), and human papillomavirus (HPV), since genetic material from this viral pathogen has been identified in a substantial number of biopsy samples, indicating a possible viral etiology of these lesions [3].

They have been reported to appear in malignant diseases, such as tumors of the kidneys and the gastrointestinal tract, presumably through the abnormal activity of epidermal growth factor (EGF) and tissue growth factor (TGF) released by the tumors.

Diabetes mellitus type 2, and the association of acrochordons and their development in patients with this metabolic disease, has been extensively researched [4] [5], and a strong link has been observed [6]. It is hypothesized that impaired insulin secretion, as well as glucose metabolism [7], are factors in the development of these skin lesions, but with variable results.

These lesions also appear as a part of a genetic disease called Birt-Hogg-Dubé syndrome, which is an autosomal dominant hereditary disorder characterized by the development of benign skin lesions, including fibrofolliculomas and trichodiscomas, as well as acrochordons, and development of lung cysts as well as pneumothorax. These finding also indicate a genetic component in the pathogenesis of acrochordon.

Epidemiology

It is estimated that almost half of the population has at least one acrochordon on their skin, and it is most commonly encountered among obese patients, while gender predilection toward female patients is observed. It is most commonly observed in late adulthood, and in the elderly, and up to 60% of the populations develop acrochordons by age of 70.

Sex distribution
Age distribution

Pathophysiology

Several theories have been suggested in the pathogenesis of acrochordon. Changes in the elastic tissue and consequent development of sessile and atrophic lesions have been proposed [8], but significant conclusions have not been made. Insulin resistance, however, has been strongly connected to the development of acrochordons, suggesting a possible mechanism of occurrence [9]. Additionally, acrochordons have been suggested as potential markers of increased risk for cardiovascular disease and atherosclerosis, as they have been observed more frequently in patients with dyslipidemia and hypertension, in addition to patients with diabetes mellitus type 2 [10].

Prevention

Preventive measures for suppressing the development of acrochordons do not currently exist, as the mechanism of occurrence is not known.

Summary

Acrochordon (also known as fibroepithelial polyp, or commonly as skin tag) is a commonly encountered small, soft, round, pedunculated polypoid formation of the skin that may appear as a single lesion, or as multiple lesions, most commonly developing in intertriginous areas, such as the axillae, groins, and the inframammary region, while the neck is also a site of common occurrence [1]. Its surface may be smooth or irregular in appearance, and histological appearance includes a thin epidermis, a fibro-vascular core, sometimes with adipose tissue.

This lesion is more commonly observed among females, and it is usually observed in adults and the elderly. The pathogenesis of acrochordons is incompletely understood, but it is believed that they occur after mechanical trauma and skin rubbing, as they most commonly appear in anatomical sites where skin rubbing is frequent, while human papillomavirus (HPV) has also been investigated and has a possible role in the development of these lesions [2]. In addition, they appear in patients with diabetes mellitus, and they tend to enlarge and become more numerous during pregnancy.

Acrochordons are usually brown or skin-colored, painless and generally asymptomatic lesions, and their size varies from a few millimeters up to one centimeter. However, they may become tender and painful after mechanical trauma or torsion, which may lead to crust formation, and possibly hemorrhage.

The diagnosis of acrochordons is made clinically, and inspection of the skin will reveal the presence of characteristic lesions. In cases when the shape and appearance are inconclusive, biopsy of the lesion and histological examination is performed. Treatment includes cryosurgery with liquid nitrogen, electrodesiccation, or snipping with scalpel or scissors.

Patient Information

Acrochordons (commonly known as skin tags) are benign skin growths that appear in about 50% of the population, and they are small, soft, painless, elevated, skin or brown-colored lesions, with the diameter ranging from a few millimeters up to one centimeter. They are composed of loose connective tissue and blood vessels, surrounded by thin skin, and they are attached to the surrounding skin by a stalk. Skin tags may appear as one lesion, but several skin tags may appear in a small area simultaneously. In cases of constant irritation, or mechanical trauma, they may become crusted and sometimes bleed in small amounts.

It is still not fully known why skin tags occur, but they most commonly appear in areas where there is frequent friction, such as the groins and the armpits, implying that repeated irritation and rubbing lead to their development. They may also appear on the neck, as well as the face including eyelids, and they have been observed more commonly in patients who have diabetes mellitus type 2, and in obese patients, which implies that insulin and glucose metabolism may play a role as well. In addition, skin tags increase in size, as well as the number during pregnancy, and hormones are also considered to be significant factors in their development. Human papillomavirus (HPV) has been identified in skin tags of some patients, which brings the hypothesis of an infectious origin as well. Still, the exact mechanism of occurrence is not known.

It is slightly more commonly observed in females than in males, and it occurs during late adulthood and among the elderly in most cases.

The diagnosis of skin tags can be made by a physician by simple inspection the lesion during the physical examination, since the characteristic appearance, shape, and other features are highly suggestive of a skin tag. However, if some other signs and symptoms appear, such as local redness of the skin, or other factors which make the diagnosis inconclusive, a skin biopsy may be ordered to confirm the diagnosis. Although it is very rare, malignant skin tumor may be identified during the biopsy, which is why it is important to perform a thorough workup.

Treatment of skin tags is not usually necessary unless irritation and repeated trauma necessitate their removal. The aesthetic reason may be another indication for treatment, which comprises removal of skin tags through several surgical techniques, including simple cutting with scissors or scalpel, cryosurgery (freezing of lesions with liquid nitrogen, and their subsequent removal) as well as electrodesiccation (burning and removal of the skin tag).

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References

  1. Libby Edwards, Peter J. Lynch. Genital Dermatology Atlas. Lippincott Williams & Wilkins. 2010; p. 209. 
  2. Gupta S, Aggarwal R, Gupta S, Arora SK. Human papillomavirus and skin tags: Is there any association? Indian J Dermatol Venereol Leprol. 2008;74(3):222-5. 
  3. Dianzani C, Calvieri S, Pierangeli A, Imperi M, Bucci M, Degener AM. The detection of human papillomavirus DNA in skin tags. Br J Dermatol. 1998;138(4):649-51. 
  4. Levine N. Brown patches, skin tags on axilla. Are this patient's velvety plaques related to his obesity and diabetes?. Geriatrics. 1996;51(10):27. 
  5. Thappa DM. Skin tags as markers of diabetes mellitus: an epidemiological study in India. J Dermatol. 1995;22(10):729-31. 
  6. Goyal A, Raina S, Kaushal SS, Mahajan V, Sharma NL. Pattern of cutaneous manifestations in diabetes mellitus. Indian J Dermatol. 2010;55(1):39-41.
  7. Mathur SK, Bhargava P. Insulin resistance and skin tags. Dermatology. 1997;195(2):184.
  8. Adams BB, Mutasim DF. Elastic tissue in fibroepithelial polyps. Am J Dermatopathol. 1999 Oct; 21(5):446-8. 
  9. Tamega Ade A, Aranha AM, Guiotoku MM, Miot LD, Miot HA. Association between skin tags and insulin resistance. An Bras Dermatol. 2010;85(1):25-31. 
  10. Sari R, Akman A, Alpsoy E, Balci MK. The metabolic profile in patients with skin tags. Clin Exp Med. 2010;10(3):193-7.
  11. Görgülü T, Torun M, Güler R, Olgun A, Kargi E. Fast and Painless Skin Tag Excision with Ethyl Chloride.Aesthetic Plast Surg. 2015;39(4):644-5. 
  12. Monfrecola G, Riccio G, Viola L, Procaccini EM. A simple cryo-technique for the treatment of cutaneous soft fibromas. J Dermatol Surg Oncol. 1994;20(2):151-2.

  • Acrochordons are not a component of the Birt-Hogg-Dube syndrome: does this syndrome exist? Case reports and review of the literature - C De la Torre, C Ocampo, IG Doval - The American journal , 1999 - journals.lww.com
  • . Dermatological Complications of Diabetes Mellitus; Allergy to Insulin and Oral Agents - ES Marmur, FR Pasternack - Principles of Diabetes , 2002 - books.google.com


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