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AUTHOR AND EDITOR INFORMATION

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Author: Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School

Robert A Schwartz is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American College of Physicians, and Sigma Xi

Coauthor(s): Agnieszka Terlikowska, MD, Staff Physician, Department of Dermatology, Medical University of Warsaw, Poland; Wanda M Patterson, MD, Department of Dermatology, UMDNJ-New Jersey Medical School

Editors: Evan R Farmer, MD, Professor of Dermatology, Johns Hopkins University School of Medicine, Clinical Professor of Pathology, Virginia Commonwealth University School of Medicine; Consulting Staff, Department of Dermatology, Johns Hopkins Hospital, VCU Health Services; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Jeffrey J Miller, MD, Associate Professor, Department of Dermatology, Penn State University, Milton S Hershey Medical Center; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center

Author and Editor Disclosure

Synonyms and related keywords: skin tags, soft fibromas, fibroepithelial polyps, FEP, fibroma pendulans, pedunculated fibromas, soft warts

INTRODUCTION

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Background

An acrochordon is a small, soft, common, benign, usually pedunculated neoplasm that is found particularly in persons who are obese. It is usually skin colored or hyperpigmented, and it may appear as surface nodules or papillomas on healthy skin. Most acrochordons vary in size from 2-5 mm in diameter, although larger acrochordons up to 5 cm in diameter are sometimes evident. The most frequent localizations are the neck and the axillae, but any skin fold, including the groin, may be affected.

Birt-Hogg-Dube (BHD) syndrome is a rare autosomal dominant genodermatosis characterized by skin tumors, including multiple fibrofolliculomas, trichodiscomas, and acrochordons.1 These patients tend to develop renal and colonic carcinomas. The defective gene in BHD syndrome has been identified and is suspected of being a tumor suppressor gene. Several mutations of the BHD gene have been reported. All skin lesions in the syndrome may actually represent fibrofolliculomas cut in various planes of section.

Related eMedicine articles of possible interest include Premalignant Fibroepithelial Tumor (Pinkus Tumor), Benign Vulvar Lesions, and Skin, Benign Skin Lesions. Additionally, the Medscape Aesthetic Medicine Resource Center may be of interest.

Pathophysiology

Previous theories have suggested that a localized paucity of elastic tissue may result in sessile or atrophic lesions. It is also thought that pendulous variations may be caused by losses of large confluent areas of elastin; however, a 1999 study of elastic tissue in fibroepithelial polyps (FEPs) showed no significant abnormalities.2

Frequency

International

Acrochordons have been reported to have an incidence of 46% in the general population.

Mortality/Morbidity

Acrochordons are benign tumors. On rare occasions, histologic examination of a clinically diagnosed FEP reveals a basal or squamous cell carcinoma. In a recent study, 5 of 1335 clinically diagnosed FEP specimens were malignant. Four were basal cell carcinomas, and one was a squamous cell carcinoma in situ. None of these specimens was submitted by a dermatologist. This study concluded that clinically diagnosed FEPs have a low probability of having malignant characteristics on histologic examination.

Sex

An equal prevalence of acrochordons exists in males and females.

Age

When present, acrochordons increase in frequency up through the fifth decade. As many as 59% of persons may have acrochordons by the time they are aged 70 years.


CLINICAL

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History

Acrochordons are flesh-colored pedunculated lesions that tend to occur in areas of skin folds.

  • A family history sometimes exists of acrochordons.
  • These tumors are usually asymptomatic, and they do not become painful unless inflamed or irritated.
  • Patients may complain of pruritus or discomfort when an acrochordon is snagged by jewelry or clothing.
  • Acrochordons may occur at unusual sites of the body. A huge acrochordon has been described on the penis.3 A lymphedematous acrochordon of the glans penis unassociated with condom catheter use also has been described.4 An acrochordon may be associated with vulval itching without the symptom being the result of fungal infection.5
  • Endoscopy may reveal FEPs arising in a ureter.6

Physical

  • Skin tags may occur singly or multiply, and they are most often found in intertriginous areas (eg, axillae, neck, eyelids) (see Media File 1). They are also commonly located on the trunk, the groin, the abdomen, and the back.
  • FEPs of the oral mucosa, anus, and vulvovaginal areas may be found.
  • These lesions may be flesh colored or hyperpigmented.
  • Three types of acrochordons are described.
    • Small, furrowed papules of approximately 1-2 mm in width and height, located mostly on the neck and the axillae
    • Single or multiple filiform lesions of approximately 2 mm in width and 5 mm in length occurring elsewhere on the body
    • Large, pedunculated tumor or nevoid, baglike, soft fibromas that occur on the lower part of the trunk
  • Pedunculated lesions may become twisted, infarcted, and fall off spontaneously.

Causes

  • Frequent irritation seems to be an important causative factor, especially in persons who are obese. An opinion also exists that acrochordons are simply the effect of skin aging, with many factors responsible for their development.
    • Hormone imbalances may facilitate the development of acrochordons (eg, high levels of estrogen and progesterone during pregnancy, high levels of growth hormone in acromegaly).
    • Epidermal growth factor (EGF) and alpha tissue growth factor (TGF) have also been implicated in the development of tumors such as these.
    • Whether any infective factors initiate acrochordon growth is still not clear.
  • Human papillomavirus (HPV) types 6/11 DNA were found in a high percentage of skin tag biopsy samples obtained from 49 white patients (see Human Papillomavirus and/or the Medscape HPV and Cervical Cancer Resource Center). According to the authors of the study, viral infection should be considered as a pathogenic cofactor.7
  • Acrochordons associated with fibrofolliculomas and trichodiscomas have been described as components of BHD syndrome, an autosomal dominant disorder. They have been reported to accompany other neoplasms, especially tumors of the gastrointestinal tract and kidneys.
    • Neoplasms are suggested to produce and release growth factors that cause acrochordon growth into the circulation.
    • The results of a recent study refute the theory that an association of acrochordons and colonic polyps actually exists.
  • An association with type 2 diabetes mellitus has been observed.8, 9
    • A study of 118 research subjects with acrochordon reported an incidence of 40.6% of either overt type 2 diabetes mellitus or impaired glucose tolerance.
    • Reports exist suggesting that the mechanism is through the effect of insulin and glucose starvation.10
    • The previous study showed no correlation between the location, size, color, or number of acrochordons with impairment of glucose tolerance.


DIFFERENTIALS

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Neurofibromatosis
Nevi, Melanocytic
Premalignant Fibroepithelial Tumor (Pinkus Tumor)
Seborrheic Keratosis
Warts, Genital
Warts, Nongenital

Other Problems to be Considered

Pedunculated seborrheic keratosis
Nodular exophytic (polypoid) melanoma
Pseudosarcomatous polyp

Rarely, a tick infestation may simulate a necrotic acrochordon.11 Metastatic melanoma may be first evident as an infarcted acrochordon.12 Squamous cell carcinoma may rarely be found within an acrochordon.13 Skin tag–like basal cell carcinomas in childhood may be a marker for basal cell nevus syndrome.14

An aggressive gross squamous cell carcinoma mass arising from a large pedunculated acrochordon located at the lower limb was recently described15


WORKUP

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Imaging Studies

A congenital perineal skin tag manifested as a perineal tumor during a second-trimester ultrasound scan at 23 weeks' gestation.16 It was an innocuous finding.

Histologic Findings

Acrochordons are characterized by acanthotic, flattened, or frondlike epithelium. A papillarylike dermis is composed of loosely arranged collagen fibers and dilated capillaries and lymphatic vessels (see Media Files 2-3). Appendages are generally absent. Acrochordons were thought to be marked by decreased numbers of elastic fibers, though one study of elastic tissue in FEPs showed no deficiency of this tissue.

Acrochordons (skin tags) are often considered clinically insignificant cutaneous redundancies that should be removed without histopathologic analysis.17 However, one may rarely find another neoplasm within an acrochordon. A squamous cell carcinoma that had features resembling a keratoacanthoma was recently described.13


TREATMENT

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Surgical Care

Skin tags are generally treated for noncosmetic reasons.

  • Small, pedunculated acrochordons may be removed with curved or serrated blade scissors, while larger skin tags may simply require excision. For small acrochordons, application of aluminum chloride prior to removal will decrease the amount of minor bleeding.
  • Anesthesia prior to electrodesiccation is another option.
  • Other methods of removal include cryotherapy and ligation with a suture or a copper wire18; however, freezing of the surrounding skin during liquid nitrogen cryotherapy may result in dyschromic lesions. Taking hold of the acrochordon with forceps and applying cryotherapy to the forceps may provide superior results.
  • A 2008 report describes a patient with circumferential prolapsed hemorrhoids with skin tags; the patient was treated with a modified Ferguson hemorrhoidectomy, with successful results.19


FOLLOW-UP

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Prognosis

  • Acrochordons are benign tumors. On rare occasions, histologic examination of a clinically diagnosed FEP reveals a basal or squamous cell carcinoma.

Patient Education

  • Advise patients that these are benign tumors.


MISCELLANEOUS

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Medical/Legal Pitfalls

  • Failure to clearly delineate how the skin tag is producing a problem for the patient when removing a symptomatic acrochordon is a pitfall. This documentation may be obligatory for insurance coverage because most plans do not cover cosmetic procedures.
  • Failure to inform the patient that the insurance company may not cover the procedure if the physician believes that he or she is performing the removal for cosmetic reasons is a pitfall.


MULTIMEDIA

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Media file 1:  A 53-year-old man with multiple, small, axillary skin tags.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 2:  A hyperplastic epidermis showing papillomatosis, hyperkeratosis, and acanthosis overlying loosely arranged collagen fibers and many capillaries.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo

Media file 3:  A higher-power view demonstrating to better advantage loosely arranged collagen fibers and many capillaries.
Click to see larger pictureClick to see detailView Full Size Image
Media type:  Photo


REFERENCES

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  1. Kawasaki H, Sawamura D, Nakazawa H, Hattori N, Goto M, Sato-Matsumura KC, et al. Detection of 1733insC mutations in an Asian family with Birt-Hogg-Dube syndrome. Br J Dermatol. Jan 2005;152(1):142-5. [Medline].
  2. Adams BB, Mutasim DF. Elastic tissue in fibroepithelial polyps. Am J Dermatopathol. Oct 1999;21(5):446-8. [Medline].
  3. Emir L, Ak H, Karabulut A, Ozer E, Erol D. A huge unusual mass on the penile skin: acrochordon. Int Urol Nephrol. 2004;36(4):563-5. [Medline].
  4. Peña KB, Parada DD. Lymphedematous fibroepithelial polyp of the glans penis non-associated with condom catheter use. APMIS. Mar 2008;116(3):215-8. [Medline].
  5. Singh N, Thappa DM, Jaisankar TJ, Habeebullah S. Pattern of non-venereal dermatoses of female external genitalia in South India. Dermatol Online J. Jan 15 2008;14(1):1. [Medline].
  6. Carey RI, Bird VG. Endoscopic management of 10 separate fibroepithelial polyps arising in a single ureter. Urology. Feb 2006;67(2):413-5. [Medline].
  7. Dianzani C, Calvieri S, Pierangeli A, Imperi M, Bucci M, Degener AM. The detection of human papillomavirus DNA in skin tags. Br J Dermatol. Apr 1998;138(4):649-51. [Medline].
  8. Levine N. Brown patches, skin tags on axilla. Are this patient's velvety plaques related to his obesity and diabetes?. Geriatrics. Oct 1996;51(10):27. [Medline].
  9. Thappa DM. Skin tags as markers of diabetes mellitus: an epidemiological study in India. J Dermatol. Oct 1995;22(10):729-31. [Medline].
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  12. Granados S, Cohen L. Metastatic melanoma presenting as an infarcted acrochordon. J Cutan Pathol. 2003;30:61.
  13. Schwartz RA, Tarlow MM, Lambert WC. Keratoacanthoma-like squamous cell carcinoma within the fibroepithelial polyp. Dermatol Surg. Feb 2004;30(2 Pt 2):349-50. [Medline].
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  16. Bord A, Valsky DV, Yagel S. Prenatal sonographic diagnosis of congenital perineal skin tag: case report and review of the literature. Prenat Diagn. Nov 2006;26(11):1065-7. [Medline].
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  19. Wang LT, Wu CC, Hsiao CW, Feng CC, Jao SW. A modified ferguson hemorrhoidectomy for circumferential prolapsed hemorrhoids with skin tags. Dis Colon Rectum. Apr 2008;51(4):456-61. [Medline].
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Acrochordon excerpt

Article Last Updated: Apr 30, 2008