In the store-and-forward teledermatology modality, there is an electronic transfer of a patient's medical information, which includes both the history and visual data obtained in one location, to a provider who is in another location (Roman & Jacob, 2015). The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
History
Chief Complaint
Presenting for diagnosis and therapeutic options.
History of Present Illness
A 53-year-old man presented with numerous (>50) skin-colored cutaneous growths in his bilateral axilla, medial thigh, and groin areas. The papules have been present for over 10 years, with several additional growths noticed every year. They are not painful unless they become caught on clothing and are not associated with itching or bleeding. His past medical history includes hypertension and Type 2 diabetes mellitus. Prior treatment: none. Primary symptom: He would prefer not to have them. Prior biopsy: none. Other significant laboratory/study findings: none.
IMAGE QUALITY ASSESSMENT
Fully satisfactory.
TELEDERMATOLOGY IMAGING READER REPORT
There is one image provided for this patient case. Figure 1 shows numerous pedunculated outgrowths (fibroepithelial polyps) involving the left medial thigh and groin.
INTERPRETATION OF IMAGES
Findings
The morphology and history of the polyps are suggestive of acrochordons (skin tags).
RECOMMENDATIONS
Given the history and clinical presentation are consistent with benign skin tags, no further laboratory evaluations are necessary. If the patient desires removal of the skin tags for cosmetic reasons or because of large size or lesion strangulation, then modalities such as "snip excision" with fine-tipped scissors, cryotherapy, electrodessication, or ligation may be utilized. As skin tags have been associated with obesity, hyperinsulinemia, metabolic syndrome, and diabetes, this patient's hemoglobin A1c should be checked to ensure that his diabetes is well controlled.
RECOMMENDED FOLLOW-UP
Reassurance. Recommend follow-up with primary care provider for education and diabetes treatment compliance.
CLINICAL PEARL
Acrochordons, commonly referred to as skin tags, are pedunculated skin growths most often found on the eyelid, neck, axilla, and inguinal folds. They are generally skin colored but may appear hyperkeratotic-lichenified or thrombosed if traumatized. These small (1-10 mm) fibroepithelial polyps can occur singly or as multiples and may be a nuisance to patients if they are irritated by rubbing against clothes or jewelry. They can spontaneously fall off if their blood supply becomes strangulated. Their appearance can also be a cosmetic issue for patients.
Histologically, acrochordons are composed of loosely arranged collagen fibers, capillaries, and lymphatic vessels. They lack hair follicles and sweat glands (Lipoff & Chatterjee, 2018). Although the exact cause of acrochordons is unknown, there are likely genetic and metabolic factors involved. Skin tag association with diabetes has been studied since the 1950s. A recent case-control study of patients with and without skin tags found a positive correlation between patients with skin tags and diabetes and impaired carbohydrate metabolism. Those with over 30 skin tags were at a particularly great risk (Rasi et al., 2007). Proposed mechanisms include hyperinsulinemia and elevated leptin. Leptin can stimulate growth factors and induce keratinocyte proliferation, whereas insulin is a growth-promoting hormone and can elevate insulin-like growth factor 1. Binding of insulin-like growth factor 1 to its receptors on keratinocytes causes epidermal hyperplasia, manifesting as cutaneous papillomas (acrochordons) or acanthosis nigricans (Jusuf et al., 2017). It has thus been suggested that increasing numbers of skin tags may be considered as a marker for hyperinsulinemia and impaired carbohydrate metabolism. In addition, as skin tags are frequently located in skin folds, it is probable that skin friction and irritation have a role in their formation.
Acrochordons affect men and women equally and are associated with increased body mass index, insulin resistance, and increasing age and can show familial inheritance (Akpinar & Dervis, 2012). Up to 46% of the population will develop acrochordons as they age (Schwartz, 2019).
REFERENCES