Acrochordon 

Updated: Apr 05, 2021
Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD 

Overview

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.[2] 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.[3, 4] All skin lesions in the syndrome may actually represent fibrofolliculomas cut in various planes of section.

Related Medscape articles of possible interest include Premalignant Fibroepithelial Tumor (Pinkus Tumor), Benign Vulvar Lesions, and Skin, Benign Skin Lesions.

Interestingly, skin tags have been used for reconstruction of the ear and of the nose, particularly for distal nasal reconstruction.[5]

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.[6]

A cross-sectional study of adult patients at a university teaching hospital, including 98 patients and 103 controls, found that the presence of multiple skin tags was strongly associated with insulin resistance, irrespective of other risk factors.[7]

In another survey, 113 patients with skin tags and 31 healthy subjects were evaluated. This work linked obesity, dyslipidemia, hypertension, insulin resistance, and elevated high-sensitive C-reactive protein with skin tags, suggesting they may serve as a marker of increased risk of atherosclerosis and cardiovascular disease.[8]

Etiology

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. According to the authors of the study, viral infection should be considered as a pathogenic cofactor.[9]

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.[10, 11, 12] 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.[13] The previous study showed no correlation between the location, size, color, or number of acrochordons with impairment of glucose tolerance. However, they may suggest early metabolic syndrome.[14]  A possible role for insulinlike growth factor in the etiology of acrochordons was suggested in a study of 30 nondiabetic persons and 30 controls.[15]

Epidemiology

Frequency

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

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.

Prognosis

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

Patient Education

Advise patients that these are benign tumors.

 

Presentation

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.[16] A lymphedematous acrochordon of the glans penis unassociated with condom catheter use also has been described.[17] Another large one was noted on vaginal labia of a 27-year-old woman.[18] An acrochordon may be associated with vulval itching without the symptom being the result of fungal infection.[19] Endoscopy may reveal FEPs arising in a ureter.[20]

Multiple skin tags are often linked with type 2 diabetes mellitus and with obesity, prompting a study of 58 people with skin tags. It showed that people with skin tags had significantly higher serum cholesterol and lower density lipoprotein levels, but not serum leptin levels, when compared with a healthy control group lacking skin tags.[21]

Acrochordons show a statistically significant relationship with obesity.[22]

Acrochordons have been linked with the components of the metabolic syndrome,[23, 24, 25] representing a cutaneous sign for impaired carbohydrate or lipid metabolism, liver enzyme abnormalities, and hypertension.[26] One survey from 2016 linked acrochordons with elevated serum triglyceride, low-density lipoprotein, very-low density lipoprotein, and leptin levels.[27] It was suggested that people with multiple acrochordons should be encouraged to reduce their weight, stop smoking, and practice healthy dietary habits.

Physical Examination

Skin tags may occur singly or multiply, and they are most often found in intertriginous areas (eg, axillae, neck, eyelids) (see the image below). They are also commonly located on the trunk, the groin, the abdomen, and the back.

A 53-year-old man with multiple, small, axillary s A 53-year-old man with multiple, small, axillary skin tags.

FEPs of the oral mucosa, anus, and vulvovaginal areas may be found. These lesions may be flesh colored or hyperpigmented. Pedunculated lesions may become twisted, infarcted, and fall off spontaneously.

Three types of acrochordons are described, as follows:

  • 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

Giant acrochordons garner considerable attention, producing considerable discomfort for patients when located in the axillae and genital regions.[28, 29, 30]

Other disorders may appear within an acrochordon. An acrochordon with histological features of lichen sclerosis was observed.[31]

 

DDx

Diagnostic Considerations

Also consider the following:

  • Pedunculated seborrheic keratosis
  • Nodular exophytic (polypoid) melanoma
  • Pseudosarcomatous polyp [32]

Rarely, a tick infestation may simulate a necrotic acrochordon.[33] Metastatic melanoma may be first evident as an infarcted acrochordon.[34] Squamous cell carcinoma may rarely be found within an acrochordon.[35] Skin tag–like basal cell carcinomas in childhood may be a marker for basal cell nevus syndrome.[36] Dermatoscopic evaluation may be of value when they are suspected, although the diagnosis of a cancer is always histologic[37]

An aggressive gross squamous cell carcinoma mass arising from a large pedunculated acrochordon located at the lower limb was recently described.[38]

An atypical lipomatous tumor classified as a well-differentiated liposarcoma located within dermis may rarely present clinically as a skin tag,[39] as may nevus lipomatosis cutaneous superficialis, an unusual benign hamartomatous disorder.[40]

Mycosis fungoides has also been documented to involve an acrochordon in a patient with known mycosis fungoides.[41] Other cancers have been rare described.[42]

Patients with skin tags might be screened for diabetes, dyslipidemia, hypertension, and cardiovascular disease.[43]

Differential Diagnoses

 

Workup

Imaging Studies

A congenital perineal skin tag manifested as a perineal tumor during a second-trimester ultrasound scan at 23 weeks' gestation.[44] It was an innocuous finding.

Incidental uptake was noted by an acrochordon on a gallium-68 prostate-specific membrane antigen positron-emission tomography scan.[45]

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 the images below). 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.

A hyperplastic epidermis showing papillomatosis, h A hyperplastic epidermis showing papillomatosis, hyperkeratosis, and acanthosis overlying loosely arranged collagen fibers and many capillaries.
A higher-power view demonstrating to better advant A higher-power view demonstrating to better advantage loosely arranged collagen fibers and many capillaries.

Acrochordons (skin tags) are often considered clinically insignificant cutaneous redundancies that should be removed without histopathologic analysis.[46] However, one may rarely find another neoplasm within an acrochordon. A squamous cell carcinoma that had features resembling a keratoacanthoma was recently described.[35]

 

Treatment

Surgical Care

Skin tags are generally treated for noncosmetic reasons. Failure to clearly delineate how the skin tag is producing a problem for the patient when removing a symptomatic acrochordon may be a cause for concern. This documentation may be obligatory for insurance coverage because most plans do not cover cosmetic procedures. Additionally, 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.

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. Some prefer ethyl chloride spray anesthesia prior to skin tag excision with microscissor and microforceps.[47]

Anesthesia prior to electrodesiccation is another option.

Other methods of removal include cryotherapy and ligation with a suture or a copper wire[48] ; 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.[49]

Long-Term Monitoring

The possibility of a relationship between skin tags and colon polyps has been considered.[50] Although they may coexist, a relationship has not been shown and is probably coincidental. Lipid profile levels in individuals with skin tags and others in the healthy population have shown no salient differences.[51]