What causes skin tags?
Skin tags are common are common. These occur to some extent due to stretching of the skin that occurs with its opening and closing, (natural “wear and tear”) and some degree of wrinkling of the skin is present in everyone. Skin tags can result from previous haemorrhoids. Once the swollen haemorrhoid full of blood resolves, the stretching causes results in a permanent area of loose skin (skin tag).
Types of skin tags.
Small flat wide based skin tags may simply be a prominent wrinkle, and this would be considered a normal variant, and does not require removal. Most people have some degree of “wrinkling” of the skin around the anus, and this is considered normal . Large skin tags that have a long narrow stalk are the easiest and safest skin tags to have removed, as the resultant wound is quite small and heals quickly. Wide based large skin tags are the most difficult and painful skin tags to remove as their removal results in a large open wound, that can take up to 6-12 weeks to fully heal (even longer if healing conditions are not ideal).
When is skin tag excision necessary?
Skin tag excision is necessary when they interfere with perianal cleaning and hygiene, resulting in discomfort and itch.
Low risk skin tags
Large long skin tags on a thin stalk are the easiest skin tags to remove with the lowest risk of complications because the wound is very small.
High risk skin tags
Large wide based skin tags are the most difficult skin tags to remove, and recovery after their removal is quite painful due to the large wound that results from their removal.
When is skin tag excision unnecessary?
Small skin tags that do not cause pain or bleeding or itch and do not interfere with your ability to clean after a bowel motion are usually best left alone. Sometimes these skin tags are unsightly, and in this case the desire to have the skin tag removed is for cosmetic reasons rather that a actually medical indication.
What is wrong with removing small skin tags for cosmetic reasons, and what complications can occur?
The problem with removing a small skin tag for cosmetic reasons, is that you may develop a regrowth of a skin tag during the healing process. Even more worrying is that you may develop failure of the wound to heal or even a painful anal fissure, particularly if you become constipated in the first 6-12 weeks after having an anal fissure excised. If you are unfortunate enough to develop a painful anal fissure after your skin tag excision, you may regret ever having surgery and wish you had just left the small asymptomatic skin tag alone. Everyone heals differently, with the scar tissue response different from one person to another. If you are someone prone to formation of scar tissue or keloid, then excision of a small asymptomatic skin tag may not be best for you, as the resultant scar may be uglier and more uncomfortable than the actual skin tag.
How quickly does the wound heal after skin tag excision?
Unlike elsewhere in the body, the anus is contaminated with bacteria, and wiped daily after a bowel motion. Attempts to close the skin after removal of a skin tag can result in infection or the wound opening up in about 50% of cases. If this happens, there is a greater chance of developing a new skin tag. Generally speaking, most colorectal surgeons would agree that leaving the wound open to heal by “secondary intention” is the safest option. In the process the skin (also called epithelium) slowly grows in from the edges until the new skin meets in the midline forming complete closure (also called re-epithelialisation).
What factors can prevent wound healing after skin tag excision?
Constipation during the healing process can result in the almost healed wound tearing. In severe cases if the tearing is significant or repeated a painful anal fissure can form. Once established an anal fissure can be quite difficult to treat requiring stool softeners, topical creams three times a day such as Rectogesic or 2% Diltiazem to relax the anal sphincter and prevent spasms. Sometimes Botox injection is required once or twice to further relax the anal sphincter and allow fissure healing. Botox is expensive ($500 per injection) with one or two injections usually required to heal most fissures. In 10-20% of cases anal fissure persists despite these measures, and surgical division of the superficial (<1cm) portion of the internal anal sphincter (called “lateral sphincterotomy) is required. This is a very successful operation for curing anal fissure, being successful in over 90% of cases, but is associated with a 3% risk of permanent faecal incontinence. For this reason it is not often offered as the first treatment option for anal fissure.
Do skin tags turn into cancer?
Simple anal skin tags do not turn into cancer.
Skin lesions that have some low risk of turning into cancer
The skin lesions that can turn into cancer include those that have wart like appearance and are due to HPV infection. If you are concerned that you may have a wart-like skin tag, then visit your colorectal surgeon who can examine you and determine if you skin tag is a simple skin tag, that will never turn into cancer, or a wart-like skin tag, where there is a small chance of it becoming cancerous if not removed.
Those with previous HPV infection may also be prone to anal neoplasia. This condition is confirmed on biopsy, and a new skin lesion in someone with anal neoplasia needs to be biopsied or removed to make sure there are not early features of cancer.
What is involved in getting a skin tag removed?
Skin tags can often be removed under local anaesthetic as a rooms procedure, and rarely required excision in hospital.
Having a skin tag excised while you are awake requires you to be tolerant of local anaesthetic injections. Usually one or two injections at the start is all you will feel during the procedure, with the actual excision painless. If diathermy (similar to laser) is used to remove the skin tag or control any bleeding, then you may feels some warmth or heat during this process.
Can I drive home or catch public transport after having a skin tag excised.
It is preferable after any surgery to have a friend or family member accompany you home in case you feel unwell or develop any side effects or bleeding after your procedure. Although excision of skin tags under local anaesthetic can be done without any sedation or general anaesthesia, sometimes the procedure can cause some anxiety or pain, and this can cause a feeling of dizziness after your procedure. For this reason it is best to have someone drive your home or accompany you home after even surgery under local anaesthetic. If this is not an option, then a period of observation until for up to an hour after your procedure is sometimes required.
When should I follow up after my skin tag excision.
There is no absolute time frame required for follow up. The most important thing is to consult your colorectal surgeon if there is significant pain and bleeding several weeks after your skin tag excision, as this may represent the development of an anal fissure, that may require assessment and treatment. If you develop significant bleeding, such as a tablespoon, then you should urgently visit your colorectal surgeon for review. Bleeding 1-2 weeks after your surgery can also be one of the first warning signs of infection, so if this occurs see your colorectal surgeon for assessment and treatment. This infection and bleeding usually settles with a five day course of antibiotics such a cephazolin (Keflex) and metronidazole (Flagyl).
How bad is the pain after skin tag excision?
The pain after skin tag excision is dependent on a number of factors, including your threshold for pain. Some people have a low threshold and some have a high threshold. The size of your wound will also be an important factor.
How is post-operative pain managed after skin tag excision.
Generally speaking the pain after skin tag excision can be adequately managed with simple over the counter pain killers such as paracetamol (Pandol) and ibuprofen (Nurofen). These simple pain killers do not cause dependence and do not cause constipation.
Stronger pain killers are rarely indicated, and if prescribed should be used cautiously, because of the risk of addiction and constipation. Typical opioid medication such as codeine or oxycodone (Endone) should not be used if at all possible. Newer generation week opioid agents such as Palexia IR are preferable to older generation opioid medications, as these are less addictive and cause less constipation.
How do I clean my wound after skin tag excision?
Water is the easiest way to clean your wound. If you don’t have a bidet (very few people do in Australia) than try using a mobile shower head in the shower after a bowel motion. Try to avoid dry scratchy toilet paper. If water is not available then try water soluble lubricating (K-Y) jelly on toilet paper, or wet wipes as an alternative.
Is salt water better than plain water.
Traditionally salt water Sitz baths with a hand full of table salt or Epsom salts added to a half full bath of warm to hot water is meant to provide antiseptic properties, however there is little evidence to support salt water being any better than plain water. The warmth of the water is the most critical factor being soothing, and overcoming the pain and spasm and irritation than can occur with anal anal wound.
Is it normal for puss to discharge from an open anal wound?
Yellow fluid discharge from an open anal wound is quite common. This may not be puss, but in fact may be the serous of mucous fluid created by your wound trying to heal, and is a natural process. Antibiotics are rarely indicated for open wounds.
On the other hand, if you develop a white discharge after closure of a wound, and this is associated with redness or warmth, then this is an indication of infection, and review by your colorectal surgeon and commencement on oral antibiotics is likely to be indicated.
What do I do if there is severe pain or bleeding after skin tag excision.
Press on the area with a pad (e.g. sanitary pad). Call our rooms on 1300 265 666, and ask to speak with your treating colorectal surgeon. If it is less than a teaspoon a day, it will usually settle. If it is more than a tablespoon and is after hours, call your colorectal surgeon’s mobile (if this has been provided to you), or call an ambulance or present to the nearest emergency department.