International Journal of Dermatology and Clinical Research
Citation: Maluki AH, Abdullah AA (2016) Metabolic Associations with Skin Tags. Int J Dermatol Clin Res 2(1): 003-011.
• Single or multiple liform lesions of approximately 2 mm in
width and 5 mm in length occurring elsewhere on the body.
• Large, pedunculated tumor or nevoid, baglike, so bromas
that occur on the lower part of the trunk .
e most common site of skin tag is on the sides of the neck, where
they may be mixed with typical small, sessile, seborrheic keratoses .
ey are also seen frequently in the axillae, eyelids, and less oen on
the trunk and groins, where the so pedunculated growths oen hang
on thin stalks , perianal skin are also frequently involved [2,8] and
this has now been named infantile perianal pyramidal protrusions.
is occurs in young children usually girls, in the midline anterior to
the anus. is reduces with time and no treatment is necessary .
Skin tag may occur at unusual sites of the body. A huge skin tags
have been described on the penis . A lymphedematous skin tag of
the glans penis unassociated with condom catheter use also has been
described . Skin tags of the oral mucosa, anus, and vulvovaginal
areas may be found .
Skin tags are usually asymptomatic, but on occasion can become
painful secondary to irritation or torsion and infarction . Patients
may complain of pruritus or discomfort when an acrochordon is
Part 1 / skin tags
Synonyms: So warts, achrochordon, cutaneous tag, papilloma
colli, broma pendulum, cutaneous papilloma, broma molluscum,
templeton skin tags , broepithelial polyps, pedunculated so
bromas, liform so bromas .
Denition: Skin tags are common benign connective tissue tumors
of the dermis , composed of loose brous tissue , and presents
as a so skin colored to slightly hyperpigmented pedunculated papule
. ese esh-colored tumors are oen raised from the surface of
the skin on a eshy stalk called a peduncle, and feel like small bags.
Skin tags may be single or multiple and are typically the size of a grain
of rice [2,6], but they may range in size from 1-2 mm papules on the
eyelids to 1-2 cm baggy polyps on the trunk . e surface of a skin
tag may be smooth or irregular in appearance .
ree types of skin tags have been described:
• Small, furrowed papules of approximately 1-2 mm in width
and height, located mostly on the neck and the axillae.
Metabolic Associations with Skin
Azar Hadi Maluki1-3* and Aala
1Department of Dermatology, College of Medicine,
University of Kufa, Iraq
2Supervisor in Al-Najaf Training Center, Council of
Arab Board for Medical Specializations, Iraq
3Supervisor in Kufa Training Center, Iraq Board for
Medical Specializations, Iraq
4Dermatology Resident, Al-Najaf Training Center,
Council of Arab Board for Medical Specializations,
Dates: Received: 31 December, 2015; Accepted:
10 February, 2016; Published: 20 February, 2016
*Corresponding author: Prof. Dr. Azar H. Maluki,
P.O. Box (450), AL-Najaf Post Ofce, Iraq. Tel:
Keywords: Skin tag; Metabolic syndrome
Background: Skin tags are small, soft, pedunculated, often pigmented lesions, usually occurring
on the eyelids, neck and axillae. There have been a few reports in the literature that the presence of
skin tag is associated with different components of the metabolic syndrome.
Objective: To evaluate the relationship between components of metabolic syndrome (atherogenic
lipid, glucose level, hypertension, and waist circumference) and other metabolic associations with skin
Patients and Methods: A total of 51 patients with skin tags aged 16 to 64 years, 13 males
(31.37%), 38 females (68.63%) with a mean age of (38.6 ± 12.1 SD); and 50 healthy controls aged
19 to 60 years, 13 males (30%) and 37 females (70%) with a mean age of (37.9 ± 9.4 SD) were
examined in dermatology outpatient clinic of Kufa Medical School Teaching Hospital, Najaf, Iraq. Body
Mass Index (BMI),waist circumference (WC),blood pressure (BP), fasting blood sugar (FBS), serum
lipids including triglyceride, total cholesterol, high-density lipoprotein cholesterol (HDL), low-density
lipoprotein cholesterol (LDL), liver enzymes (AST, ALT), alkaline phosphatase and serum uric acid
were measured for both study groups. The study was approved by Ethics Committee of Kufa Medical
School in Iraq.
Results: There was no signicant statistical difference in fasting blood sugar, serum uric acid,
liver function tests, triglyceride, high density lipoprotein and very low density lipoprotein between the
study groups. Patients group has showed signicantly higher levels of total cholesterol and LDL, when
compared with the healthy controls group (P < 0.01). Also patients group showed signicantly higher
values of BMI, blood pressure (BP), and Waist circumference (WC) compared with the healthy controls
group (p = 0.0001), ( p = 0.001) and (P < 0.01) respectively. It has been found that 37 (72.5%) of the
patients and 13 (26%) of the controls meet at least three of the criteria of metabolic syndrome.
Conclusion: Total cholesterol and LDL serum levels should be checked in patients with skin
tags. On the other hand, glucose, serum levels may not be as important as what is being considered
in recent time.
Citation: Maluki AH, Abdullah AA (2016) Metabolic Associations with Skin Tags. Int J Dermatol Clin Res 2(1): 003-011.
Maluki and Abdullah (2016)
snagged by jewelry or clothing . Vulvovaginal skin tag may be
associated with itching without the symptom being the result of
fungal infection . Skin tags are harmless, and may not grow or
change over time .
Incidence: e condition is very common, particularly in middle-
aged and elderly people [9-12] and their incidence increases with age,
and close to 46% - 50% of all individuals have at least one skin tag
[5,7], with nearly 60% of individuals acquiring them by the age of 69
years . An equal prevalence of skin tags exists in males and females
, but some studies suggested that skin tags are common particularly
in middle age and elderly women [9-12], where they found together
with seborrheic keratosis .
Causes and precipitating factors: Frequent irritation in areas of
skin friction , seems to be an important causative factor, especially
in persons who are obese [4,13,14]. An opinion also exists that skin
tags are simply the eect of skin aging, with many factors responsible
for their development . Hormone imbalances may facilitate the
development of skin tags (ex. high levels of estrogen and progesterone
during pregnancy, high levels of growth hormone in acromegaly).
Epidermal growth factor and alpha tissue growth factor 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 types 6 and 11 DNA was 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 .
Skin tags associated with brofolliculomas and trichodiscomas
have been described as components of Birt-Hugg-Dube syndrome,
an autosomal dominant disorder. ey 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 skin tags growth in to the circulation ,
whereas in Cowden disease the skin tags are sclerotic broma .
An association with type - 2 diabetes mellitus has been observed
[16-19]. 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 eect of insulin and glucose starvation
[20-22]. e previous study showed no correlation between the
location, size, color, or number of skin tags with impairment of
glucose tolerance . ey oen increase in number when the patient
is gaining weight or during pregnancy, and may be related to the
growth hormone-like activity of insulin.
In patients preselected for gastrointestinal complaints, skin
tags appear to be more prevalent in those with colonic polyps. is
association has not been proved for the general population [2,7].
A family history of acrochordon sometimes exists .
Observations of skin tags and obese people were the rst to indicate a
genetic correlation to skin tags. Scientists were looking for the reasons
why some patients had skin tags and other patients didn’t and noted
that skin tags were seen to consistently exist within families. A logical
conclusion was that there was a link in the DNA of aected people
e skin tags may represent a cutaneous sign for impaired
carbohydrate or lipid metabolism , liver enzyme abnormalities and
hypertension . In one study report that skin tags are associated
with various components of the metabolic syndrome , no data in
the literature show that the presence of skin tags is associated with
serum high-sensitive C- reactive protein, uric acid, free fatty acid and
leptin level .
Mast cells and tumor necrosis factor ”TNF”-α may play a role in
the pathogenesis of skin tags following trauma to the skin, in the form
of friction, “TNF-related apoptosis-inducing ligand” is upregulated
and can induce mast cell migration into the skin through the release
of chemokines. Mast cells in turn release TNF-α. e latter, through
direct or indirect interactions with broblasts and keratinocytes
could initiate some of the changes that lead to the formation of skin
Part 2 / metabolic syndrom
Metabolic syndrome (syndrome X, insulin resistance syndrome)
refers to a cluster of known disorders that increase the risk for
morbidity and mortality from cardiovascular disease and type - 2
diabetes. Risk for type - 2 diabetes mellitus increases ve to nine fold
with metabolic syndrome .
Metabolic syndrome (Table1) is a complex cluster of several risk
factors within a single patient according to the National Cholesterol
Education Program / Adult Treatment Panel (ATP) lll, which are
directly related to the incidence of coronary heart disease [20,23].
Evolving perspectives on the denition of metabolic
In addition to the ATP III clinical identication of the metabolic
syndrome (Table 1) various organizations have set forth clinical
criteria for its diagnosis . Although similar in many aspects to
other guidelines, the World Health Organization clinical criteria
for the metabolic syndrome regard insulin resistance as a required
component for diagnosis of the syndrome [25-27]. Furthermore
any two of ve other risk factors are regarded as sucient to meet
the denition of metabolic syndrome. Requiring objective evidence
of insulin resistance may provide a stronger prediction of type - 2
diabetes mellitus than ATP lll; however, consistent with ATP lll
ndings, type - 2 diabetes mellitus does not exclude a diagnosis of the
metabolic syndrome .
e American Diabetes Association recently conducted an
Table 1: National Cholesterol Education Program (NCEP), Adult Treatment
Panel lll (ATP lll). Diagnosis of metabolic syndrome includes at least 3 of the
• Large waist circumference < 102 cm (40 inches) for men, and < 88 cm (35
inches) for women.
• Serum triglyceride (TG) levels ≥ than 150 mg/dl.
• Level of high-density lipoprotein cholesterol (HDL-C) > 40 mg/dl for men,
and > 50 mg/dl for women.
• Hypertension: Blood Pressure (BP) ≥ than 130/85 mmHg.
• Fasting glucose level (FBS) ≥ than 110 mg/dl.
Citation: Maluki AH, Abdullah AA (2016) Metabolic Associations with Skin Tags. Int J Dermatol Clin Res 2(1): 003-011.
Maluki and Abdullah (2016)
extensive review of the literature relating to the metabolic syndrome
and uses the term metabolic syndrome to refer to a clustering
of specic cardiovascular disease risk factors whose underlying
pathophysiology is thought to be related to insulin resistance .
e American Diabetes Association acknowledges that certain
cardiovascular disease risk factors are prone to cluster. However,
their recommendation is that further research is needed (including
studies that investigate the pathogenesis of the metabolic syndrome)
and that clinicians should evaluate and treat all cardiovascular disease
risk factors without regard to whether a patient meets the criteria for
diagnosis of the metabolic syndrome .
World health organization criteria for metabolic syndrome:
Insulin resistance, identied by one of the following:
• Type - 2 diabetes mellitus
• Impaired fasting glucose
• Impaired glucose tolerance
• Or for those with normal fasting glucose levels (> 110 mg/
dL), glucose uptake below the lowest quartile for background
population under investigation under hyper-insulinemic or
Plus any two of the following:
• Antihypertensive medication and / or high blood pressure (≥
than 140 mm Hg systolic, or ≥ than 90 mm Hg diastolic).
• Plasma triglycerides ≥ than 150 mg/dL (1.7 mmol/L).
• High-density lipoprotein cholesterol > 35 mg/d (0.9 mmol/L)
in men, or > 39 mg/dL (1.0 mmol/L) in women.
• Body mass index of < 30 kg/m2 and/or waist to hip ratio of <
0.9 in men, or less than 0.85 in women.
• Urinary albumin excretion rate ≥ than 20 ~ tg/min or albumin
to creatinine ratio ≥ than 30 mg/g.
Atherogenic dyslipidemia clinically presents as elevated serum
triglyceride levels, increased small dense low-density lipoprotein
particles, and decreased levels of high density lipoprotein - cholesterol
[29,30]. All of these abnormalities have been implicated as being
independently atherogenic. e three abnormalities of elevated serum
triglycerides, increased small dense low-density lipoprotein particles,
and low high density lipoprotein - cholesterol have been termed the
atherogenic lipoprotein phenotype  or, more simply, the lipid
triad. is multiplex array of lipid abnormalities is a powerful risk
factor for coronary heart disease, dened as angina pectoris, unstable
angina, myocardial infarction, or coronary death [32,33].
Etiology: Risk factors for metabolic syndrome include family
history, poor diet, and inadequate exercise.
Metabolic syndrome is thought to be caused by adipose tissue
dysfunction and insulin resistance. Dysfunctional adipose tissue
also plays an important role in the pathogenesis of obesity-related
insulin resistance . Both adipose cell enlargement and inltration
of macro-phages in to adipose tissue result in the release of pro
inammatory cytokines and promote insulin resistance . Insulin
resistance appears to be the primary mediator of metabolic syndrome
. Insulin promotes glucose uptake in muscle, fat, and liver
cells and can inuence lipolysis and the production of glucose by
hepatocytes . Additional contributors to insulin resistance include
abnormalities in insulin secretion and insulin receptor signaling,
impaired glucose disposal, and pro inammatory cytokines. ese
abnormalities, in turn, may result from obesity with related increases
in free fatty acid levels and changes in insulin distribution (insulin
accumulates in fat). e distribution of adipose tissue appears to
aect its role in metabolic syndrome. Fat that is visceral or intra-
abdominal correlates with inammation, whereas subcutaneous fat
does not. Abdominal fat is known to produce potentially harmful
levels of cytokines, such as tumor necrosis factor, adiponectin, leptin,
resistin, and plasminogen activator inhibitor. Lifestyle factors such
as alcohol consumption, cigarette smoking, and physical activity
have been reported to aect an individual’s metabolic prole [37,38].
Studies have also reported an inverse relationship between physical
activity and certain components of metabolic syndrome such as
waist circumference, high density lipoprotein - cholesterol and blood
Clinical Presentation of metabolic syndrome: may include the
• Reduced high-density lipoprotein cholesterol.
• Abdominal obesity.
• Chest pains or shortness of breath: Suggesting the rise of
cardiovascular and other complications.
• Acanthosis nigricans, hirsutism, peripheral neuropathy,
and retinopathy: In patients with insulin resistance and
hyperglycemia or with diabetes mellitus.
• Xanthomas or xanthelasmas: In patients with severe
Diagnosis: According to guidelines from the National Heart,
Lung, and Blood Institute and the American Heart Association,
metabolic syndrome is diagnosed when a patient has at least 3 of the
following ve conditions:
• Fasting glucose ≥110 mg/dL (or receiving drug therapy for
• Blood pressure ≥130/85 mm Hg (or receiving drug therapy
• Triglycerides ≥150 mg/dL (or receiving drug therapy for
• High density lipoprotein – cholesterol <40 mg/dL in men or
< 50 mg/dL in women (or receiving drug therapy for reduced
high density lipoprotein – cholesterol).
Maluki and Abdullah (2016)
Waist circumference ≥102 cm (40 in) in men or ≥88 cm (35 in)
in women; if Asian American, ≥90 cm (35 in) in men or ≥80 cm (32
in) in women .
Part 3 / association between skin tags and metabolic
Multiple skin tags have been associated with abnormalities in the
glucose metabolism, specically type - 2 diabetes, hyperinsulinemia
and insulin resistance. Insulin resistance is a state in which a given
concentration of insulin produces a less than expected biological
eect. Obesity is the most common cause. is is followed by
compensatory hyperinsulinemia to maintain normal glucose and
lipid homeostasis [40,41].
Dierent methods are available for assessment of insulin resistance,
of which calculation of the homeostasis model assessment of insulin
resistance provides a useful approach [41,42]. Hypertension, diabetes
and metabolic syndrome were signicantly more frequent in patients
with acrochordons than the control group, according to the study
on a total of 192 patients with at least one skin tag and 104 controls
having no skin tag seen at an academic outpatient dermatology
clinic were involved. According to regression analysis, the number
of acrochordons increased in patients with higher body mass index
values, 2-h plasma glucose, triglyceride and low density lipoprotein
- cholesterol levels and lower high density lipoprotein - cholesterol
levels. ese results support the suggestion that acrochordons are
associated with the components of metabolic syndrome [42,43] and
the risk of atherosclerosis and cardiovascular disease . One study
shows that the skin tags are not associated with increased incidence of
obesity compared to the general population. On the other hand, skin
tags are associated with impaired carbohydrate metabolism, and may
serve as means for identifying patients at increasing risk of having
diabetes mellitus , yet the relation of skin tags to obesity is still a
matter of controversy .
Clinical and metabolic glucose/insulin characteristics of men
with multiple (8 or more) skin tags on the neck were compared with
a control group with few or none. One-third of the study group had
acanthosis nigricans. Multiple skin tags were more sensitive than
acanthosis nigricans in identifying those with alterations in the
glucose/insulin metabolism, although less specic. Multiple skin tags
should raise suspicion of insulin resistance or hyperinsulinemia .
e possible association of skin tag with diabetes mellitus was
rst mentioned in 1951. Since then, a few clinical studies have
been conducted to examine this hypothesis with conicting results.
Diabetes or impaired glucose tolerance had greater number of skin
tags compared to normo-glycemic ones, but there was no signicant
dierence between number of skin tags in diabetes and impaired
glucose tolerance group, in addition, patients with more than 30 skin
tags (designated as high number) had signicantly higher incidence
of impaired carbohydrate metabolism than patients who had less
than 30 skin tags.
ere is no positive correlation between number of skin tags and
body mass index, similarly, the mean number of skin tags in obese,
over weight and normal weight was not signicantly dierent. No
correlation was found between the anatomical location of skin tag
and the presence of abnormal carbohydrate metabolism, except for
skin tags under the breast in women . Specic dermatoses as skin
tags, striae distensae and plantar hyperkeratosis, could be considered
as a cutaneous stigma of severe obesity. Although the physiological
mechanisms are still unknown, nding has not been previously
described and that this may constitute new eld in the research on
obesity . Acrochordons were found to be closely associated with
pseudo-acanthosis nigricans, seborrheic keratosis, obesity and non-
insulin dependent diabetes mellitus . A study included irty-six
patients with skin tags and 22 healthy controls, the mean levels of
body mass index, homeostasis model assessment of insulin resistance,
and total cholesterol were signicantly higher in patients than in
So skin tags may not be innocent tumoral proliferations; instead,
follow-up of such patients with regard to the development of diseases
associated with atherosclerosis may benecial .
Aim of the study
To evaluate the possible relationship between components
of metabolic syndrome (atherogenic lipid, serum glucose level,
hypertention and waist circumference); and other metabolic
associations with the occurrence of skin tags .
Patients and Methods
A total of 51 patients and 50 healthy controls, matched in age
and sex, were included in the study. Patients and controls were
recruited from Dermatology Outpatient Clinic of Kufa Medical
School Teaching Hospital, Najaf, Iraq. All subjects were examined by
a dermatologist; patients were dened as persons with skin tags at
any body site and controls as persons having no skin tag. Skin tag
was diagnosed clinically as a eshy pedunculated so protrusion skin
colored or brownish, aecting the exural areas or face. Personal
history of hypertention, diabetes, hyperlipidemia, drug intake,
smoking, missed period in female, and family history of skin tags was
recorded for both groups.
Exclusion criteria from the study for both groups were:
• Patients receiving drugs with a known antihyperlipidemic
• Pregnant women.
• Patients who are known cases of hypertension or receiving
drugs with a known antihypertensive eect.
• Patients who are known cases of diabetes mellitus or receiving
drugs with a known hypoglycemic eect.
e height, weight, waist circumference (in inch) and body mass
index (BMI) of patients and controls were measured.
Body mass index “BMI” was calculated by dividing body weight
to height square (kg/m2). Patients were considered according to their
• BMI ≤ 18 as thin.
• BMI between 19 and 25 as normal.
Maluki and Abdullah (2016)
• BMI between 26 and 29 as overweight.
• BMI ≥30 as obese.
Where the height of patients was measured by using a rubbery
tape measure and approximated to nearest 0.5 cm and weight of
patients was taken by weight measuring device. Waist circumference
was measured (in inch) by a rubbery tape measure, by nding the
top of hip bone and the bottom of the last rib, then ask the person to
breathe out normally and place the tape measure midway between
these points and wrap it around the waist. Blood preasure was
measured to both groups by sphygmomanometer.
All patients and controls were informed about the aim and
procedure of the study. Investigations were performed for both groups
in the study including liver function tests (Alanine transaminase
“ALT”, Aspartate transaminase “AST”, Alkaline phosphatase “ALP”)
and serum uric acid (by autoanalyzer device). Blood samples of
the patients and controls were taken aer (at least) an eight-hour
starvation, to measure fasting blood sugar, serum total cholesterol,
triglyceride, and High density lipoprotein – cholesterol values (by
Low density lipoproten – chelesterol and very low density
lipoproten – chelesterol values were calculated according to the
• Very low density lipoproten – chelesterol = triglyceride /
(divided by) 5.
• Low density lipoproten – chelesterol = cholesterol – (minus)
(Very low density lipoproten – chelesterol + High density
lipoprotein – cholesterol).
Normal values (according to the standards of the Teaching
Hospital Laboratory) were as follows:
• Total cholesterol : 0-199 mg/dl.
• Triglyceride : 0-149 mg/dl.
• High density lipoproten : 40-60 mg/dl.
• Low density lipoproten : 100-129 mg/dl.
• Very low density lipoproten : 5-40 mg/dl.
• Uric acid : 3.50-7 mg/dl.
• Alanine transaminase “ALT”: 0-55U/L.
• Aspartate transaminase “AST”: 5-34U/L.
• Alkaline phosphatase “ALP”: 40-150U/L.
• Fasting blood sugar: 70-99 mg/dl.
According to Adult Treatment Panel III criteria of metabolic
syndrome (Table 1), those who met at least three criteria were
included in a group called (metabolic syndrome group).
All the results were expressed as means ± (Standard Deviation
“SD”) values. e signicance of the dierence between the groups
was assessed by unpaired Student’s t-test for continuous variables. e
chi-square test or Fischer’s Exact test was used for testing prevalence
between groups, Pie charts and Bar chart were used as needed. e
statistical analysis was performed using Statistical Package for the
Social Science “SPSS” Version 20 program, and P values of < 0.05
were considered as signicant.
is study has been approved by the Ethics Committee of Kufa
Medical School, Iraq. All individuals in study groups have informed
A total of 51 patients with skin tags with ages of 16 to 64 years,
including 13 males (31.37%) and 38 females (68.63%) with a mean age
of (38.6 ± 12.1 SD), (Figures1,2); in addition to 50 healthy controls
aged 19 to 60 years, 13 males (30%) and 37 females (70%), (Figure
3) with a mean age of (37.9 ± 9.4 SD); were examined in the present
study. A positive family history of skin tags was present in 50 (98%)
Table 2: Clinical characterestics of study groups.
(mean ± SD) Control
(mean ± SD) P value
BMI 32.5±6.2 27.1±5.3 0.0001
Blood pressure Systolic 136.3±16.2 126.8±9.4 0.001
Diastolic 84.1±11.8 75±6.6 0.001
Waist Circumference Female 37.7±4.7 34.7±3.9 0.005
Male 39.7±3.8 34.8±3.2 0.001
Smoking Positive 5 (9.8%) 2 (4%) 0.25
Negative 46 (90.2%) 48 (96%)
Family history Positive 50(98%) 4(8%) 0.0001
negative 1(2%) 46 (92%)
Table 3: Liver function tests, fasting blood sugar and serum uric acid values in
study groups. Patients (mean ± SD) Controls(mean±SD) P value
AST 17.2±6.3 18.9± 8.4 0.263
ALT 21.2±9.4 20.9± 7.9 0.943
ALP 107.8±27.9 107.4±34.9 0.958
FBS 112.9±38.7 106.1±23.6 0.23
SUA 4.7±1.2 4.5±.83 0.28
Table 4: Lipid prole in study groups.
Patient (mean±SD) Control(mean±SD) P value
Cholesterol 204.5±43.7 177.02±35.8 0.001
TG 151.8±69.8 134.3± 59.9 0.215
HDL 34.3±11.5 37.04±8.7 0.178
VLDL 29.9± 10.7 27± 12.3 0.264
LDL 137.1±37.8 113.1±31.4 0.001
Table 5: Occurance of metabolic syndrome in study groups.
Group Total No. (%) P value
Metabolic syndrome Present 37(72.5%) 13(26%) 50(49.5%) 0.0001
Absent 14(27.5%) 37(74%) 51(50.5%)
Total 51(100%) 50(100%) 101(100%)
Maluki and Abdullah (2016)
Patients group showed signicantly higher levels of total
cholesterol and low density lipoproten, when compared with the
healthy controls group (P = 0.001), while no signicant dierences in
triglyceride, high density lipoprotein and very low density lipoprotein
were present between the two groups (Table4) . Also patients group
showed signicantly higher values of body mass index, blood pressure
and waist circumferenceV when compared with the healthy controls
(p = 0.0001), ( p = 0.001) and (P < 0.01) respectively; (Figures4,5 and
Depending on the Adult Treatment Panel III criteria for diagnosis
of metabolic syndrome that was mentioned (Table 1), it was found
that 37 (72.5%) of patients and 13 (26%) of controls met at least three
of the criteria of metabolic syndrome; while 14 (27.5%) of the patients
and 37 (74%) of controls failed to meet those criteria, with a p value of
(P = 0.0001) which was highly signicant (Table5).
In the present study we found that (80.4%) of the patients were
above the age of 30 years, with the larger percentage occur between
(30 to 39) years of age, while (19.6%) of the patients were below the age
of 30 years, and they were mostly female (68.63%), and this support
the suggestion that skin tags are more common in women or may be
explained by the fact that women are seeking medical interference for
cosmetic purposes more than men .
Family history was positive in (98%) of the patients and in only
(8%) of controls; and this supports the role of genetic factor in the
pathogenesis of skin tags.
Multiple skin tags are frequently associated with non-insulin-
dependent diabetes mellitus and obesity . Obesity is a factor
that has been associated with the development of skin tags .
In the present study, body mass index of patients was signicantly
higher than controls with a (P=0.0001); and patients were mostly
obese (68.63%), while (19.61%) were over weight and these results
support the suggestion of association of skin tags with obesity.
According to the study of Shaheen M.A. et al., which agrees with
older studies, a suggestion was made that android pattern of obesity
is to be more predictive of insulin resistance than body mass index,
and accordingly, waist circumference appears to be the most related
criteria of the metabolic syndrome that correlates positively with the
number of skin tags in dierent body mass index patients . In
the present study we found the waist circumference which is one of
the components of metabolic syndrome is signicantly higher in the
patients group when compared with controls (P = 0.005 for females,
and P = 0.001 for males) . So we could conclud that skin tags show a
statistically signicant relationship with obesity.
A supposed relation is found between diabetes millettus and skin
tags. A study done by Rasi et al. , investigated oral glucose tolerance
test with 75g glucose and showed an increased risk of diabetes mellitus
in patients with skin tags . However, we could not nd this kind
of relationship in the present study where we found no signicant
statistical dierence in fasting serum glucose levels between the
groups ; and this might be due to the fact that we have not tested our
patients for oral glucose tolerance test. On the other hand, our result
is similer to that obtained from a study done by Gorpelioglu C et al.
Figure 1: Age distribution in patients group.
Figure 2: Sex distribution in patients group.
Figure 3: Sex distribution in controls.
of patients and 4 (8%) of controls. On the other hand, 5 (9.8%) of
patients and 2 (4%) of controls were smokers (Table2). ere was no
signicant dierence in fasting blood sugar, serum uric acid or liver
function tests between the two groups (Table3).
Maluki and Abdullah (2016)
, but in their study the patients and controls had a similar body
mass index (28.7 ± 7.9) ; therefore, they thought that the relationship
between skin tags and diabetes mellittus might be associated with the
patients having obesity and obesity related glucose intolerance, while
in the present study the body mass index is signicantly higher in the
patients when compared with controls group (p > 0.0001). Similarly,
in another study, Marthur et al., estimated insulin resistance in 10
patients with multiple skin tags and 10 control subjects matched
for age, sex and body weight. ey concluded that skin tags are not
markers of insulin resistance and it is possible that epidermal growth
factor or other growth factors may play a role in the pathogenesis of
skin tags .
ere are only few studies about the relationship between skin tags
and atherogenic lipid prole. Crook investigated serum lipid prole
in four patients with skin tags and found increased serum triglyceride
and decreased HDL cholesterol . Erdogan et al., found increased
total cholesterol in 36 patients with skin tags, when compared with 22
healthy controls . Gorpelioglu C et al. , found total cholesterol
levels and low density lipoproten serum levels were higher in patients
with skin tags, when compared with the healthy control group. e
last two studies meet the results of the present study, that showed
the total serum cholesterol and low density lipoproten serum levels
were signicantly higher in patients with skin tags in comparison
to healthy controls (P = 0.001) for both, however, there was no
statistically signicant dierence in the serum triglycerides, high
density lipoproten, very low density lipoproten serum levels in both
groups (P= 0.215, P=0.178, P= 0.264) respectively.
Skin tags could represent a cutaneous sign for impaired
carbohydrate or lipid metabolism, liver enzyme abnormalities and
Insulin resistance syndrome or metabolic syndrome is a collection
of health risks that increases the chance of developing heart disease,
stroke and diabetes. Various risk factors have been included and the
factors generally accepted as being characteristic of this syndrome
include abdominal obesity, raised blood pressure, atherogenic
dyslipidaemia and insulin resistance with or without glucose
intolerance . Hypertension, diabetes and metabolic syndrom were
signicantly more frequent in patients with skin tags than the control
group, according to the study on a total of 192 patients with at least
one skin tag and 104 controls having no skin tag seen at an academic
outpatient dermatology clinic were involved . e acrochordon group
showed signicantly higher values of body mass index, higher levels
of aspartate amino transferase, alanine amino transferase, gamma-
glutamyl transferase, alkaline phosphatase, triglycerides, triglycerides
and low density lipoproten – cholesterol and signicantly lower levels
of high density lipoproten – cholesterol when compared with the
control group. e number of skin tags is increased in patients with
higher body mass index values, 2-h plasma glucose, triglycerides and
low density lipoproten – cholesterol levels and lower high density
lipoproten – cholesterol levels.
ese results support the suggestion that skin tags are associated
with the components of metabolic syndrome, and with the risks of
atherosclerosis and cardiovascular disease .
In the present study the summery of results that explain the
associations between skin tags and components of metabolic
syndrome includes: Waist circumference and blood pressure were
signicantly higher in patients with comparison to controls group.
While the triglycerides, high density lipoproten, fasting blood
sugar, showed no statistically dierences between the two groups.
But generally, we found 37 (72.5%) of the patients and 13 (26%) of
controls meet at least three of the criteria of metabolic syndrome.
ese results are also in agreement with a study proposed that skin
tags are cutaneous ndings frequently associated with the risk factors
for metabolic syndrom and heart disease, and recommended that
these patients should be carefully evaluated for metabolic syndrom
and heart disease (24). Our results showed no association between
skin tags and liver enzymes abnormalities or serum uric acid, and
there were no signicant dierences between the values of liver
enzymes (Aspartate transaminase “AST”, Alanine transaminase
“ALT” and Alkaline phosphatase “ALP”) between the patient and
control groups (p=0.263, p=0.943, p=0.958) respectively.
Conclusions and Recommandations
We may propose that skin tags may be one of the important
skin markers of metabolic disorders and may attract physicians and
dermatologist for further investigation as it is proved to be not just a
cosmetic problem .
Figure 4: BMI distribution in patients group.
Figure 5: BMI distribution in controls.
Maluki and Abdullah (2016)
e results of this study advice the screening of patients with
skin tags for hypercholesterolemia, increased level of low density
lipoproten (when positive, other components of metabolic syndrome
are preferably to be measured).
is leads us to recommend the change of life style of patients
with skin tags and / or hyperlipidemia, as stopping active smoking and
prevention of passive smoking, regular exercises, weight reduction,
changing carbohydrate diets into high protein diets.
Knowing that diets rich in polyunsaturated fatty acids as olive oil,
omega 3, 6 and 9 fatty acids supplementation can decrease the risk of
coronary atherosclerosis, we recommend their use for patients with
skin tags and/or hyperlipidemia.
Because our study consisted of a limited number of patients and
controls from asingle population, further studies done with larger
patient groups will be benecial in elucidating the relationship
between skin tags and atherosclerotic risk factors.
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