Presentation: The lesions are usually pedunculated on a thin stalk. The length of stalk varies, and the lesions are about 0.5 to 2.5 mm in diameter. Skin tags often appear round and soft and are easy to diagnose simply by a visual examination. Smaller lesions may be visible with the use of a magnifying glass. The skin tag may be the same color as the skin or be hyperpigmented; in general, the latter is more common. Skin tags are most on the side of the neck, axillary region, and groin.[6]

Acrochordons have the following general descriptions:

• 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:- solo or multiple filiform skin tags that are roughly 5 mm long and 2 mm wide, occurring at other sites on the body

• Large-sized skin tags: - pedunculated lesions that may demonstrate a baglike, nevoid, baglike appearance, or soft fibromas usually located on the lower part of the body (groin)

Giant skin tags attract considerable attention, as they are known to produce significant discomfort for patients when located in the axillae and genital regions.

The patient should undergo evaluation for diabetes mellitus by ordering levels of A1c, fasting blood glucose, and postprandial blood glucose. Additionally, the patient's lipid profile should requires monitoring. The clinician should record the patient's BMI should and serially follow it.

There are several treatments of skin tags, and all require removal of the lesion. Today, the use of radiocautery in the office is the most commonly performed procedure. Other methods of removal include the following:

• Snip excision
• Cautery 
• Cryosurgery 

Smaller skin tags are also removed using the nanosecond Q-switched Nd: Yag or the CO2 laser. Some patients may require an injection/topical application of a local anesthetic to minimize the pain. After excising the skin tag, the tiny wound usually heals on its own.

In most cases, the treatment almost always consists of excision and removal using radio cautery, snip excision, or cryosurgery. However, most specialists prefer radio cautery due to its ease of use and precision.

Risks associated with skin tag removal

Skin tag removal is primarily a low-risk clinic 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 heavy bleeding or the development of an aberrant infection after the surgery. The clinician can mitigate the risk for complications by taking a proper history of any prescription or over-the-counter medications the patient might be taking since some drugs, and herbal supplements can alter the bleeding and clotting times.

It is also crucial that the patient follows proper instructions on how to care for the area of skin tag removal; this will reduce the risk of infection after the procedure. The patient must never try to remove the skin tags at home. Without proper technique and a sterile environment, the risk for excessive bleeding and infection increases.

• Dermatologic manifestations of neurofibromatosis type 1, in some instances, resemble skin tags.

• Genital warts sometimes also resemble skin tags.

• Melanocytic nevi resemble hyperpigmented skin tags.

• Nongenital warts resemble skin-colored skin tags.

• Premalignant fibroepithelial tumor (Pinkus tumor) is rare but could be a consideration.

• Seborrheic keratosis is again a rare but possible differential diagnosis.

Skin tags are usually benign, and after excision, the histopathology reports confirm the same in most cases.

The skin tag, if left unchecked, may increase in size due to the constant friction with clothing and skin fold. However, the histological features remain the same, and these lesions have a very low or no risk of malignancy.

A skin tag may twist on its pedicle and become inflamed; in many cases, obese individuals exhibit an increased risk of inflammation.[7]

Complications of Removal

• Scarring can occur with improper removal of the skin tag.
• Sometimes normal skin tissue can be removed, which can lead to changes in cosmesis. Thus, the need to seek assistance from an experienced clinician.
• Mild irritation and even irritant dermatitis may occur in the area where the skin tag removal took place.
• Rarely, a neuroma may result if a nerve growth in the skin tag gets cut, resulting in chronic pain for some weeks or even months.

Proper moisturizing agents help in the skin regrowth and also reduce the risk of irritant dermatitis.

Patients should understand that skin tags are benign lesions, but they may carry correlations with type 2 diabetes or obesity, hence the need to maintain healthy body weight and blood glucose levels. Patients with type 2 diabetes require monitoring by an endocrinologist to ensure control of blood glucose levels.[8]

For those with skin tags around the neck, they should be told to avoid wearing jewelry on the neck to prevent skin irritation and friction injuries.

Furthermore, the patient should be told to avoid wearing restrictive and synthetic clothing, which can also cause friction in the presence of a skin tag.

Patients should be encouraged to lose weight, eat a healthy diet, and perform regular exercise; this not only helps lower the risk of obesity and diabetes, but it may also help with the prevention of skin tag formation. In some studies, the use of syndet bars for bathing and proper moisturizing have been shown to prevent skin tags and also reduced the local complications.[9]

Skin tags or acrochordons should not be considered as an isolated entity as they are more likely to be seen in diabetic patients and individuals with metabolic syndrome. Also, in young females in the second and third decades of life, skin tags may be seen in the presence of polycystic ovarian syndrome; thus, it is important to investigate these patients for these comorbidities. Simply excising the skin tag may improve the cosmesis, but one may miss a metabolic disorder ifs one omits further investigations. Various studies have indicated the correlation of skin tags and metabolic diseases like DM type 2; hence, a complete workup and follow up treatment should be the norm.[10]

Primary care clinicians should be fully aware that even though skin tags have no malignant potential, if they have any doubt about the lesion, they should order a referral to a dermatologist.

Removal of skin tags is a simple and non-eventful procedure when performed by trained individuals. However, the patient has to be encouraged to change his or her lifestyle. Otherwise, the lesions may recur in the future. A dermatology specialty-trained nurse can prove to be an invaluable asset in preparing the patient, assisting during the procedure, attending to the patient post-operatively, and providing patient counsel. The clinician or specialist and the nurse need to function as an interprofessional healthcare team to optimize patient outcomes in these cases. [Level V]