Friction Induced Skin Tags
Published Web Locationhttps://doi.org/10.5070/D30cs6h02d
Friction Induced Skin Tags1. Department of Dermatology, Complejo Hospitalario Universitario de Vigo Vigo, Spain. email@example.com 2. Department
of Pathology, Complejo Hospitalario Universitario de Vigo Vigo, Spain
Francisco Allegue MD1, Carmen Fachal MD2, Lidia Pérez-Pérez MD1
Dermatology Online Journal 14 (3): 18
Skin tags are common benign neoplasm located predominantly in intertriginous skin. Generally of cosmetic concern, they can be easily treated with cryotherapy, electrodessication or snip-excision. Despite their high incidence data about their etiopathogenesis are scarce in the medical literature. We describe a patient who developed multiple skin tags arranged in a linear fashion suggesting an etiopathogenic role for friction.
Skin tags (ST), also named soft fibromas, achrocordons or fibroepithelial polyps, are very common benign dermal connective tissue neoplasms. They usually occur as small, soft, pigmented or skin-colored, filiform, often pedunculated lesions on intertriginous areas. The neck, axillae, eyelids, groin and perianal skin are frequently involved. They appear more often in patients over age 50 .
ST have received little attention in the dermatological literature and are often considered clinically insignificant cutaneous redundancies that should be removed and destroyed without performing histopathologic study. However histopathologic examination may reveal another benign cutaneous lesions arising within ST and more rarely a true neoplasm . In other instances histopathologic examination of lesions clinically resembling ST may reveal Crohn's disease , basal cell carcinoma in nevoid basal carcinoma syndrome [4, 5] or features of the fibrofolliculoma/trichodiscoma spectrum . We report herein the case of a patient with multiple skin tags due to frictional movements she had been doing at work.
A 42-year-old, otherwise healthy, obese woman, was referred to our outpatient clinic, complaining of multiple, soft, pedunculated, skin-colored tumors arranged in a linear fashion on her back, shoulders and costal regions and randomly distributed in her axillae. They were located on a pigmented and velvety skin, but signs of acanthosis nigricans were not present in other body sites. The distribution of these lesions corresponded closely to the position of her brassiere straps.
|Figure 1||Figure 2|
|Figure 1. Multiple soft pediculated lesions arranged in a linear fashion following the brassiere straps. Note that some of
the lesions had been already treated with electrodessication.|
2. Detail of the linear arrangement
She stated that she had begun to work in a chicken slaughterhouse several years ago. The tumors began to appear after this work and had been increasing in number since then. She had to move her arms up and down hundreds of times in a working day. Frequently the lesions became inflamed and necrotic. During this time she did not experience evident weight gain nor she became pregnant. No signs of hiperandrogenism or evident endocrinopathies were recognized. Her blood count and biochemistry parameters were all within normal ranges.
|Figure 3. Histopathology of an achrocordon|
Histopathologic examination of one of these lesions revealed a connective tissue axis composed of fibrous collagen with telangiectatic vessels, covered by a hyperkeratotic and acanthotic epidermis.
A diagnosis of friction-induced ST was made. ST were removed by snipping with curved scissors and electrodesiccation. The patient was advised to avoid wearing tight clothing, since the patient was not keen on leaving her job.
Etiopathogenetic data about ST are scarce, despite their great frequency. The association of acanthosis nigricans, skin tags, diabetes mellitus due to insulin resistance, and obesity in adolescents and young adults represents a well defined syndrome  Severe insulin resistance typically presents as disordered glucose metabolism including both diabetes and/or paradoxical hypoglycemia, with acanthosis nigricans, often associated with skin tags, or hyperandrogenism in girls . Our patient did not have overt diabetes mellitus, but we can not exclude impaired carbohydrate metabolism, because we did not perform a glucose tolerance test or insulin level. Although skin tags are more commonly associated with diabetes than with obesity , control of obesity contributes largely to reversing the whole process, essentially by reducing both insulin resistance and compensatory hyperinsulinemia . Pregnancy is also a risk factor for the development of ST . Although it has been suggested, ST are not associated with a higher risk for colonic polyps than that expected in the general population . Other etiopathogenic mechanisms have been proposed in anecdotal reports: drug-induced , human papillomavirus related  or as a type of cutaneous stigmata in different forms of occult spinal dysraphism . An association between ST and acromegaly  or prolactinoma  has been reported.
Skin tags appeared in our patient after she began to work in the chicken's slaughterhouse, and they appeared progressively since then. We think that friction due to obesity and a tight brassiere along with repetitive movements at work all played a major in role in inducing ST. However, a search in Medline using as key words "friction/frictional forces/frictional injury" and "skin tags" (or synonyms) did not show any true reference stating a causal association between the two conditions. Frictional injury to the skin causes inter- and intra-cellular edema of the epidermis, and if severe, produces membranous rupture and formation of an intra-epidermal blister . However exposure of the skin to repeated low intensity frictional forces results in a number of changes including cellular proliferation and epidermal thickening, which may both reduce the likelihood of blisters  and promote ST.
References1. Weedon D. Skin Pathology. 2nd Ed. London, Churchill Livingstone, 2002.
2. Schwartz RA, Tarlow MM, Lambert WC. Keratoacanthoma-like squamous cell carcinoma within the fibroepithelial polyp. Dermatol Surg 2004; 30:349-50 PubMed
3. Taylor BA, Williams GT, Hughes LE, Rhodes J. The histology of anal skin tags in Crohn's disease: an aid to confirmation of the diagnosis. Int J Colorectal Dis 1989; 4: 197-9 PubMed
4. Chiritescu E, Maloney ME. Acrochordons as a presenting sign of nevoid basal cell carcinoma syndrome. J Am Acad Dermatol 2001; 44:789-94 PubMed
5. Lortscher DN, Sengelmann RD, Allen SB. Acrochordon-like basal cell carcinomas with basal cell nevus syndrome. Dermatology Online Journal 13(2): 21 PubMed
6. De la Torre C, Ocampo C, García-Doval I, Losada A. Cruces MJ. Acrochordons are not a component of the Birt-Hogg-Dube syndrome: does this syndrome exist? Case reports and review of the literature. Am J Dermatopathol 2000; 22:293-4 PubMed
7. Hermanns-Lê T, Scheen A, Piérard GE. Acanthosis nigricans associated with insulin resistance : pathophysiology and management. Am J Clin Dermatol. 2004; 5:199-203 PubMed
8. Savage DB, Semple RK, Chatterjee VK, Wales JK, Ross RJ, O'Rahilly S. A clinical approach to severe insulin resistance. Endocr Dev. 2007;11: 122-32 PubMed
9. Scheinfeld NS. Obesity and dermatology. Clin Dermatol. 2004; 22: 303-9 PubMed
10. Sand C. Topical tacrolimus ointment may induce skin tags in treated patients. Acta Derm Venereol 2003; 83: 317 PubMed
11. Dianzani C, Calvieri S, Pierangeli A, Imperi M. Bucci M, Degener AM. The detection of human papillomavirus DNA skin tags. Br J Dermatol 1998; 138:649-51 PubMed
12. Schropp C, Sorensen N, Collmann H, Krauss J. Cutaneous lesions in occult spinal dysraphism-correlation with intraspinal findings. Childs Nerv Syst 2006; 22:125-31 PubMed
13. Rodríguez-Serna M, Martínez A, Pérez A, Medina E, Aliaga A. Eruptive skin tags and keratoacanthomas in a patient with prolactinoma and colonic polyps. Dermatology 1994; 189:215-6 PubMed
14. Knapik JJ, Reynolds KL, Duplantis KL, Jones BH. Friction blisters. Pathophysiology, prevention and treatment. Sports Med 1995; 20:136-47 PubMed
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