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SKIN TAGS AND ITS ASSOCIATION WITH SYSTEMIC ILLNESSES

BACKGROUND AND OBJECTIVES: Skin tags (Acrochordons) are very common benign tumor of the skin. It is seen in 25% of population, particularly in women in advancing age and in pregnancy. Skin tags are small, soft, pedunculated and papillomatous lesions usually seen on eyelids and major flexures of the body. Skin tags are entirely asymptomatic and diagnosis is unmistakable. Many cutaneous lesions have been well established to be associated with some systemic diseases and this has been proven beneficial as it helps in early diagnosis. METHODS: A total no of 50 patients with skin tags were included in the study. Detailed history, thorough physical examination and relevant investigations were done to confirm the systemic manifestations when present. RESULTS: In the study the patient’s age ranged from 18–65 yrs with female male ratio 1:1.17. The number of skin tags among the 50 patients ranged from 1–74. In our study we found that 74% of our patients with skin tags were either obese or overweight, 24% of our patients fulfilled the criteria of metabolic syndrome, 36% of the patients were diabetics & 4 of our patients had evidence of thyroid disorder. INTERPRETATION & CONCLUSION: Presence of multiple, hyper pigmented skin tags at more than one site can be a marker for diabetes, obesity and metabolic syndrome. All such patients should be evaluated thoroughly for detecting such illnesses. This study thus emphasizes the need for systemic evaluation of all patients with skin tags for early management and improved quality of life by life

The Statistical software namely SPSS 15.0 has been used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc.
In the study 92% of the patients had Skin tags measuring less than 1 cm, only 4 patients (8%) had giant skin tags measuring more than 1cm [ Table 4].
In the study about 44% of patients presented with skin tags in 2 sites, 32% in 3 sites, 20% in single site and 4% in 4 sites. The systemic illnesses were more commonly noted in patients with 2 or 3 sites involvement [ Table 9] The investigations carried on the patient were recorded and interpreted.
DISCUSSION: Skin tags are common benign lesions of the skin. The risk of getting skin tags increases with age. The age of 50, however, seems to be a turning point, at which a stagnation of the increase is observed. In our study there is more prevalence of skin tags among men than women. The majority of the carriers had no more than 3 tags per localization; the most frequent localization was the neck, followed by the axilla, eyelids, groin and others. 80% of our patients had lesions in more than one site. Our findings suggest that when multiple sites are involved chances of associated systemic illnesses being present are more likely. There were no secondary changes noted in the skin tags of our patients. Acanthosis nigricans is a hyper pigmented velvety plaque present symmetrically, most commonly in the axilla, groin and posterior neck. The hyper pigmentation observed is secondary to acanthosis and papillomatosis of the epidermis rather than pigment producing cells. The skin proliferation abnormalities in acanthosis are due to hyperinsulinemia and insulin resistance. 7 Hud et al 8 found that 74% of an obese patients had acanthosis nigricans along with elevated plasma insulin levels. Several studies have suggested Acanthosis nigricans to be a marker for metabolic syndrome. Our study also reveals that patients with skin tags who had Acanthosis nigricans had more evidence of other systemic illnesses, we postulate on this finding that skin tags can also be considered as a marker for metabolic syndrome. Recent data demonstrate a significantly higher prevalence of obesity among psoriasis patients than in the general population 9 . In our study only one patient had evidence of Psoriasis vulgaris.
The association between skin tags and obesity/ overweight has yielded mixed results in the past. Rasi A et al, in their study of 110 patients with skin tags revealed that 26.9 per cent were obese and 42 patients were overweight. 10 However kahana et al did not find an increased incidence with obesity but did report that those patients with Acrochordons had greater impairment of carbohydrate metabolism. 11 In our study we found that 74% of our patients with skin tags (40 & 34) were either obese or overweight. We therefore postulate that skin tags are an important marker for overweight and obesity.
24% of our patients fulfilled the criteria of metabolic syndrome as defined by the National Cholesterol Education Program's ATPIII. 12 In addition 10% had partial findings of metabolic syndrome. With these findings we postulate that skin tags could also be considered as a cutaneous marker for metabolic syndrome. However study involving a larger population will help bring more light on this subject.
In our study 36% of the patients were diabetics. Other studies have reported a much lower prevalence rate of diabetes mellitus in their patients with skin tags. 11 It is not surprising for our higher figures, considering that we have a higher prevalence of diabetes mellitus in our general population and also the fact that most of our patients also had other features of metabolic syndrome either completely or incompletely. We suggest that diabetes in many patients is occurring as complication of obesity evident by late onset of disease in many cases. Differences in genetic background, diet, levels of physical activity, population age and sex, levels of over and under nutrition, and body habits all influence the disease prevalence.
More than 50% of our patients had a positive family history of skin tags which is slightly more than the study done by Banik R et al. 13 In addition significant number of patients also had a positive family history of diabetes and hypertension. The findings suggest that there could be a genetic abnormality in the coexistence of these three diseases.
Our study failed to reveal any involvement of colonic disorders in our patients, although metabolic syndrome increases the risk of colon cancer mortality. 14 Lesser population studied and not focusing on investigation towards detection of colonic disorders could be a cause. However studies done earlier have also reported conflicting results. 4 of our patients had evidence of thyroid disorder. This is much higher when compared to prevalence of thyroid disorders in general population. 3 of the patients were hypothyroid and one had hyperthyroidism, but there was no evidence of clinically significant nodules has suggested by the Rezzonico et al. 15 The study was cross-sectional and therefore the directionality (whether skin tags occurred first or other illnesses preceded skin tags) of the association between skin tags and systemic illnesses could not be determined.

CONCLUSIONS:
Skin tags are a common finding present more commonly after age of 40 yrs.
Presence of multiple, hyper pigmented skin tags at more than one site can be a marker for diabetes, obesity and metabolic syndrome. All such patients should be evaluated thoroughly for detecting such illnesses.
Skin tags can be early marker of increased risk of atherosclerosis and cardiovascular disease and helps in prevention of long term complications if diagnosed earlier.
Our study has got the limitations of having been done on a smaller population; we recommend study of similar type on a larger population to be made to corroborate our findings.

SUMMARY:
Skin tags are a common benign lesions occurring in the general population. The patients were assessed clinically and investigations were carried out.
This study was intended to determine its association with various systemic illnesses. There is a significant association with diabetes, obesity and metabolic syndrome.
Patients with skin tags presented to the hospital should be thoroughly assessed and advised about the risk of systemic illnesses it could be associated with. Life style modification at early stage helps to prevent development of diseases or its long term associations.