Continuing Education Activity

Skin tags, or acrochordons, represent common benign cutaneous outgrowths that arise from the epidermis and underlying dermis. Lesions typically present as soft, pedunculated papules on a narrow stalk, most often in intertriginous areas such as the neck, axillae, groin, and eyelids. The prevalence of lesions increases with age, obesity, and metabolic syndrome, and numerous epidemiological studies link acrochordons with type 2 diabetes, dyslipidemia, insulin resistance, and polycystic ovarian syndrome. Skin tags typically lack malignant potential; however, the presence of multiple or recurrent lesions frequently signals underlying metabolic derangements and warrants further evaluation. Recognition of characteristic morphology, growth patterns, and common anatomic locations allows accurate diagnosis and differentiation from entities such as warts, nevi, seborrheic keratoses, neurofibromas, and rare adnexal or premalignant tumors. Appropriate management focuses on both removal of lesions for cosmetic or symptomatic relief and identification of associated systemic disorders that may benefit from early intervention.

The participants learn to recognize the clinical significance of acrochordons beyond cosmetic concerns and to integrate dermatologic findings into a broader metabolic risk assessment. The course emphasizes interpretation of history, physical examination, and simple diagnostic workup, including glucose parameters, lipid profile, and anthropometric measurements, to uncover comorbid obesity, insulin resistance, or endocrine disorders. The participants gain practical skills in selecting and performing safe office-based removal techniques, and in counseling patients on lifestyle modification, skin care, and the avoidance of friction-related triggers. Collaboration with an interprofessional team, such as dermatology clinicians, endocrinologists, primary care clinicians, nurses, and dietitians, enhances screening accuracy, supports coordinated management of cardiometabolic risk factors, and improves adherence to therapeutic recommendations. Shared decision-making, clear communication, and role delineation within this team-based approach ultimately optimize long-term outcomes for patients presenting with acrochordons.

Objectives:

• Differentiate acrochordons from other benign and premalignant cutaneous lesions through clinical and histopathological findings.
• Assess the association between skin tags and underlying metabolic conditions, including obesity, insulin resistance, and type 2 diabetes.
• Implement evidence-based procedural techniques for the safe and effective removal of skin tags while minimizing complications.
• Collaborate with dermatology, endocrinology, and primary care professionals to ensure comprehensive evaluation and management.

Introduction

Skin tags, also known as acrochordons, are benign soft excrescences of redundant skin. Studies show that approximately 50% to 60% of adults develop at least 1 of these harmless growths during their lifetime, with the likelihood of occurrence increasing after the fourth decade of life. However, acrochordons occur more commonly in individuals with obesity, diabetes mellitus, or metabolic syndrome and in those with a family history of skin tags. Skin tags affect men and women equally.

Acrochordons may appear as early as adolescence but are more common in later life. Many studies have reported that the incidence of skin tags in children and adolescents is increasing. This trend seems to align with the global rise in childhood obesity. Skin tags, on the other hand, are rare after the seventh decade of life. These lesions tend to grow in areas with skin folds, such as the axilla, neck, eyelids, and groin (see Images. Skin Tags on the Neck and Skin Tags in the Axilla). The lesions are skin-colored, brown, or red ovoid growths that are often pedunculated and attached to a fleshy stalk. Skin tags are small, measuring 1 to 5 mm, and rarely grow to 1 to 2 cm. Acrochordons are neither painful nor tender but can be troublesome. Patients often report that skin tags catch on clothing or jewelry, such as necklaces. Occasionally, the constant friction between the garments and the skin tag can cause bleeding or itching. Certain genetic disorders may predispose to the development of skin tags, such as Birt-Hogg-Dube syndrome and tuberous sclerosis.[1][2] In addition to other cutaneous and systemic features, acrochordons may be numerous, often forming a necklace-like configuration known as the molluscum pendulum necklace sign.

Etiology

Skin tags are associated with abnormal lipid profiles, type 2 diabetes, cardiovascular disease, obesity, and genetic factors.[3][4] Frequent skin irritation has been implicated as a cause, particularly in individuals with obesity. Experts believe that acrochordons are a normal consequence of skin aging and the subsequent loss of elasticity. Hormonal imbalances may potentiate the development of skin tags (eg, elevated levels of progesterone and estrogen, or increased human growth hormone in acromegaly). Transforming growth factor-α and epidermal growth factor may be risk factors or triggers for skin tags.

The presence of multiple cutaneous tags is significantly associated with insulin resistance, independent of other risk factors, according to results from a cross-sectional study of adult patients at a university teaching hospital.[5] In an additional survey, a correlation was observed between skin tags and obesity, dyslipidemia, hypertension, insulin resistance, and elevated high-sensitivity C-reactive protein, suggesting that they may serve as risk indicators for cardiovascular disease and atherosclerosis.[6] Although infectious etiologies have not been reported as causes of acrochordons, anecdotal reports suggest that some viruses may be responsible. In several investigations, human papillomavirus infection has been linked to skin tags.[7]

Skin tags have also been reported, though rarely, in association with other disease processes. For example, a 12-year-old child presented with perianal skin tags and growth impairment as initial manifestations of asymptomatic Crohn disease.[8] In another case, a 37-year-old man with several skin tags and brownish lichenoid papules was diagnosed with mycosis fungoides. The papule and skin tag showed superficial, thick, band-like lymphoid infiltrates and epidermotropism of atypical lymphocytes (Pautrier microabscesses) on histopathology.[9]

Epidemiology

Acrochordons have a reported prevalence of 50% to 60% in the general population.[4] Prevalence is similar in men and women. Once a skin tag has developed, it may increase in size or number with advancing age. By the fifth or sixth decade, approximately two-thirds of individuals may develop acrochordons, which persist throughout life.

Pathophysiology

The pathogenesis of acrochordons remains elusive, despite their prevalence. Acrochordons consist of various histologically distinct tumors, including small skin protrusions, multiple lesions on the neck and axilla, and a much larger pedunculated tumor known as a soft fibroma. Findings from a study suggest that somatic mutations in the overlying epidermis of HRAS, KRAS, PIK3CA, EGFR, or FGFR3 may drive the development of skin tags on the neck and axilla.[10] The ultraviolet signature is relatively insignificant in the driver mutations of skin tags and seborrheic keratosis, perhaps because of the limited number of specific mutations, predominantly noncytosine to thymine alterations, that elicit constitutive, active modifications in the causal gene products. Future research should explore the molecular mechanisms underlying fibrous stroma formation in skin tag development, encompassing signals or mechanical forces induced by skin friction, mesenchymal microenvironmental factors such as localized dermal laxity that promote skin protrusion, and the proposed contraction force exerted by the overlying epidermis that distorts the collagenous stroma and induces skin protrusion.

Histopathology

Acrochordons are typically benign on histopathology reports. Acrochordons are distinguished by acanthotic, flattened, or flowery-patterned (papillomatous) epithelium. The papillary dermis consists of loosely organized collagen fibers, along with dilated capillaries and lymphatic vessels. Appendages are typically missing. Although acrochordons were formerly believed to contain reduced amounts of elastic fibers, one study of the elastic tissue in fibroepithelial polyps found sufficient elastic fibers.[11] Acrochordons are typically regarded as clinically unimportant cutaneous outgrowths that can be excised without histopathological examination.[12] Furthermore, it is uncommon to encounter a second neoplasm within an acrochordon. However, a single case of squamous cell carcinoma with features similar to those of a keratoacanthoma was reported.[13] Additionally, an acrochordon exhibiting histological characteristics of lichen sclerosus has also been reported.[14]

History and Physical

The lesions are typically pedunculated on a thin stalk, with stalk length varying and lesion diameters ranging from 0.5 to 2.5 mm. Skin tags are often round and soft and can be easily diagnosed by visual examination (See Image. Skin Tag Appearance). Smaller lesions may be visible with a magnifying glass. Skin tags are typically hyperpigmented, but they can also match the skin color. Skin tags are most often found on the lateral neck, axillae, and groin.[15]

Acrochordons can be categorized into several general types:

• Small skin tags: Furrowed papules of approximately 1 to 2 mm in width and height, most frequently appearing on the neck and the axillae.
• Mid-sized skin tags: Single or multiple filiform skin tags that are approximately 5 mm long and 2 mm wide, occurring at other sites.
• Large skin tags: Pedunculated lesions that may appear bag-like, nevoid, or soft fibromas. These tags are typically found on the lower part of the body (groin).
• Giant skin tags: These tags can cause significant discomfort when located in the axillae and genital regions.

In a rare case, a 5-year-old child with type 1 diabetes presented with skin tags as a manifestation of acanthosis nigricans (see Image. Skin Tags Associated with Acanthosis Nigricans).[16]

Evaluation

In patients presenting with multiple or recurrent skin tags, a thorough metabolic evaluation is strongly recommended. The clinician should evaluate for diabetes mellitus and insulin resistance using appropriate laboratory tests, including HbA1c, fasting blood glucose, and postprandial blood glucose. In addition to these standard parameters, the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) has now emerged as a relevant and sensitive marker for detecting early or subclinical insulin resistance and should be considered where feasible.

A complete lipid profile should be obtained to evaluate dyslipidemia, given the frequent association between metabolic syndrome and cutaneous markers such as acrochordons. The clinician should also monitor body mass index over time, as weight gain and central obesity are both risk factors for skin tags and metabolic derangements. Regular follow-up and documentation of these parameters help establish trends and enable early intervention, thereby reinforcing dermatologists' role in identifying and preventing systemic metabolic disorders through cutaneous manifestations.

Treatment / Management

In most cases, treatment consists of excision and removal using radiocautery, snip excision, or cryosurgery (see Image. Skin Tag Removal Using Radiocautery). However, most specialists prefer radiocautery due to its ease of use and precision. Smaller skin tags are also removed using a carbon dioxide laser. Some patients require an injection or topical application of a local anesthetic to minimize pain. After excising the skin tag, the tiny wound typically heals without further intervention. Alternative methods for skin tag removal include cryotherapy and suture or copper wire ligation. However, dyschromic lesions may develop as a consequence of freezing the surrounding skin during liquid nitrogen cryotherapy. Improved outcomes may be achieved using forceps to grasp the acrochordon and applying cryotherapy.[17] Rubber band ligation with negative pressure can be employed for removing anal skin tags, resulting in a satisfactory cosmetic outcome. The same technique was used to ligate necrotic and ischemic hemorrhoidal tissues.[18] Results from a study showed that treatment with the 532-nm lithium triborate laser—characterized by its bloodless and dressing-free approach—was superior. However, scissor snip excision showed improved wound healing, reduced discomfort, and higher patient satisfaction. These data indicate that scissor snip excision is the best treatment for pedunculated fibromas, but more research is needed on the 532-nm laser and other lasers for tiny, dispersed fibromas.[19]

Skin tag removal is primarily a low-risk office-based procedure. However, the lesion often freely bleeds when removed, requiring pressure and monitoring during the procedure. On occasion, coagulation with silver nitrate or electrocautery is necessary. In rare cases, the patient may experience excessive bleeding or develop a postoperative infection. The clinician can mitigate the risk of complications by obtaining a detailed history of any prescription or over-the-counter medications the patient is taking, as some drugs and herbal supplements can alter bleeding and clotting times.

Patients should receive proper instructions on caring for the area after skin tag removal to reduce the risk of infection. Patients should not attempt to remove the skin tags at home. Without proper technique and a sterile environment, the risk for excessive bleeding and infection increases. Proper moisturizing agents help promote skin regrowth and reduce the risk of irritant dermatitis. 

Differential Diagnosis

The differential diagnosis for skin tags includes other cutaneous lesions such as warts (genital or extragenital), nodular exophytic (polypoid) melanoma, melanocytic nevi, pedunculated seborrheic keratosis, and pseudosarcomatous polyp.[20] Furthermore, dermatologic manifestations of neurofibromatosis type 1 can resemble skin tags. A premalignant fibroepithelial tumor (Pinkus tumor) is rare but should be considered. Additionally, tick infestation may mimic a necrotic acrochordon. Basal cell carcinomas that resemble skin tags in childhood may serve as a diagnostic indicator for basal cell nevus syndrome.[21] Nevus lipomatosis cutaneous superficialis, an uncommon benign hamartomatous disorder, may occasionally manifest clinically as a skin tag, as can an atypical lipomatous tumor classified as a well-differentiated liposarcoma located within the dermis.[22][23] An acrochordon in a patient with known mycosis fungoides has also been documented.[24]

Prognosis

If left untreated, skin tags may grow larger due to constant friction with clothing and skin folds. However, the histological features remain the same, and these lesions have a very low or no risk of malignancy.

Complications

A skin tag may twist on its pedicle and become inflamed; often, individuals with obesity are at increased risk of inflammation.[25]

Complications of Removal

• Scarring can occur with improper removal of the skin tag, resulting in cosmetic disfigurement.
• Mild irritation and irritant dermatitis may occur at the site of skin tag removal.
• Rarely, a neuroma may form if a nerve within the skin tag is transected, causing chronic pain for several weeks or even months.

Deterrence and Patient Education

Patients should be educated that skin tags are benign lesions, but they may be associated with type 2 diabetes or obesity; therefore, weight loss, smoking cessation, and healthy dietary practices are needed. Patients with type 2 diabetes require monitoring by an endocrinologist to ensure control of blood glucose levels.[26] Patients with skin tags around the neck should be advised to avoid wearing neck jewelry to prevent skin irritation and friction injuries. Furthermore, patients should be advised to avoid wearing restrictive or synthetic clothing, as this can also increase friction around a skin tag.

Pearls and Other Issues

Patients should be encouraged to lose weight, follow a healthy diet, and engage in regular physical activity; this not only helps lower the risk of obesity and type 2 diabetes but may also help prevent skin tag formation. In some studies, the use of syndet bars for bathing and proper moisturization prevented skin tag formation and reduced local complications. Please see StatPearls' companion resource, "Acrochordon," for further information.[27] Unless there are metabolic, gastrointestinal, or biochemical signs, skin tags do not correlate with colonic polyps and do not warrant a screening colonoscopy.[28]

Enhancing Healthcare Team Outcomes

Skin tags, or acrochordons, should not be considered an isolated entity because they are more common in patients with diabetes mellitus and metabolic syndrome. Furthermore, in young women in the second and third decades of life, skin tags may be associated with polycystic ovarian syndrome; thus, it is crucial to evaluate these patients for these comorbidities. Simply excising the skin tag may improve the cosmesis, but a metabolic disorder can be missed. Various studies have indicated a correlation between skin tags and metabolic diseases such as type 2 diabetes; hence, a complete evaluation and follow-up treatment should be the norm.[29]

Primary care clinicians should be aware that, although skin tags have no malignant potential, they should refer the patient to a dermatologist if they have any concerns. Removal of skin tags is a simple procedure when performed by trained clinicians. However, the patient should be encouraged to adopt lifestyle modifications. Otherwise, the lesions may recur. A dermatology specialty–trained nurse is an invaluable asset in preparing the patient, assisting during the procedure, attending to the patient postoperatively, and providing patient counseling. The clinician or specialist and the nurse need to function as an interprofessional healthcare team to optimize patient outcomes in these cases.

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Disclosure: Amarendra Pandey declares no relevant financial relationships with ineligible companies.

Disclosure: Haitham Saleh declares no relevant financial relationships with ineligible companies.