Atlas of Primary Care Procedures, 1st Edition

Dermatology

13

Skin Tag Removal

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 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 are rare in childhood, and when found, they may indicate the presence of other disorders such as nevoid basal cell carcinoma syndrome. 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. Skin tags in adults historically have been associated with the presence of adenomatous colonic polyps, but some studies suggest that the association is unclear. Some clinicians recommend routine screening with occult blood testing and flexible sigmoidoscopy for individuals whose only risk for colon pathology is the presence of skin tags.

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 later. 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 destruction 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 can be employed, and it 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.

P.105

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 scissors removal allows for 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 45–65 tags per session. Because residual scarring depends on the depth of dermal injury, scarring can be minimized with scissors removal. Histologic assessment is offered to patients but may not always be necessary if the experienced clinician removes small, characteristic tags. Application of antibiotic ointment usually promotes rapid (moist) healing of the site.

INDICATIONS

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

CONTRAINDICATIONS

  • Pigmented skin lesions (especially flat lesions) generally should not be shaved or destroyed because of the possibility of the lesion being a melanoma, which requires assessment of depth for accurate staging and treatment. 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.

P.106

 

PROCEDURE

Most lesions can be rapidly removed without anesthetic. When lesions have a wide base (>2 mm), consider administering a small bleb of 1% lidocaine with epinephrine beneath the lesion.

 

(1) Consider administering a small bleb of 1% lidocaine with epinephrine beneath a lesion if it has a base wider than 2 mm.

Use the nondominant hand. Most skin tags can be removed without anesthesia and with limited discomfort if the removal is performed rapidly from stretched skin. The nondominant thumb and index finger should forcefully stretch the skin surface to provide countertraction and to stretch pain fibers.

 

(2) 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 due to 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.

P.107

 

Use sharp, new, curved 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 (Figure 3A). Wedge the closing blades of the scissors beneath the lesion, making sure no surrounding skin is caught between the blades (Figure 3B). Talk to the patient; verbal anesthesia helps. Tell the patient to take a deep breath, and rapidly cut the tag free (Figure 3C). Apply Monsel's solution (i.e., ferric subsulfate) or aluminum chloride solution to the wound base for hemostasis.

 

(3) Use sharp, new, curved iris scissors.

PITFALL: Straight iris scissors can be used by experienced clinicians but often inadvertently pull surrounding tissue into the blades of the scissors. Use a side-to-side rocking motion to wedge the lesion beneath the blades of the scissors to prevent trauma to surrounding skin.

The base of the lesion is anesthetized, and cautery current is applied to the lesion. Wipe away the necrotic tissue with gauze after the destruction.

 

(4) Electrocautery destruction.

PITFALL: Avoid full-thickness or deep burns, because greater scarring is produced.

P.108

 

CODING INFORMATION

CPT® Code

Description

2002 Average 50th Percentile Fee

11200

Removal (any method) of up to 15 multiple tags, any area

$115

11201

Removal of each additional 10 lesions (list separately)

$73

CPT® is a trademark of the American Medical Association.

INSTRUMENT AND MATERIALS ORDERING

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 destruction is performed, see Chapters 19, 20, 38 and 39 for a description of the needed equipment. Skin preparation recommendations appear in Appendix H.

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.

Coleman WP, Hanke CW, Alt TH, Asken S. 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 lesion. J Am Acad Dermatol 2000;43:306–307.

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, ed. 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.