A giant skin tag of the scrotum and verruca anogenitalis

A 65-year-old Caucasian male presented with a 6x4x3 cm mass on the scrotal skin. The patient admitted that the lesion had been present for about ten years and it increased in size gradually. The past medical history was unremarkable. Physical examination revealed a hyperpigmented, erythematous, polypoid mass hanging from the left scrotal skin with a peduncle. The lesion was soft and nontender to palpation. In addition, there was a hyperkeratotic, skin colored, small papule on the left scrotum above the giant polypoid mass measuring 2x3x4 mm in size (Fig. 1). The patient stated that the small lesion appeared for about two months ago. Both of the lesions were removed surgically under local anesthesia to reach a definitive diagnosis (Figs. 2a and 2b). Histopathological examination of the polypoid mass and the small papule revealed a skin tag and verruca anogenitalis, respectively.


Sir,
A 65-year-old Caucasian male presented with a 6x4x3 cm mass on the scrotal skin.The patient admitted that the lesion had been present for about ten years and it increased in size gradually.The past medical history was unremarkable.Physical examination revealed a hyperpigmented, erythematous, polypoid mass hanging from the left scrotal skin with a peduncle.The lesion was soft and nontender to palpation.In addition, there was a hyperkeratotic, skin colored, small papule on the left scrotum above the giant polypoid mass measuring 2x3x4 mm in size (Fig. 1).The patient stated that the small lesion appeared for about two months ago.Both of the lesions were removed surgically under local anesthesia to reach a definitive diagnosis (Figs.2a and 2b).Histopathological examination of the polypoid mass and the small papule revealed a skin tag and verruca anogenitalis, respectively.
A skin tag, also known as acrochordon or fibroepithelial polyp, is a common benign mesenchymal tumor.It usually presents as a small, pedunculated polyp in intertriginous areas such as neck, axilla, groin and face.Rarely, skin tags may appear in the respiratory tract, orophyarynx, female and male genitalia [1,2].Skin tags affect 46% of the general population.Moreover, they are usually seen in elderly women during perimenopausal and postmenopausal period [2].Genetic predisposition, obesity, impaired glucose tolerance, diabetes mellitus and hyperlipidemia may be the causative factors [1][2][3].Furthermore, human papilloma virus (HPV) infection may play role in the etiology of skin tags [3].
Giant skin tags are rare, and a few giant skin tag cases have been reported previously to the best of our knowledge.Ghosh et al. reported four cases with giant skin tags on unusual localizations including nipple (3x2.5 cm), eyelid (0.5x2 cm) and right thigh (2.5x2.5 cm) [2].Yan et al. reported a 62-year-old patient with a giant skin tag measuring 7x5x3 cm on penis with verrucous appearance [1].Ilango et al. described a giant skin tag measuring 12x8 cm on the back with variable pigmentation [4].Colak et al. presented a female with a giant skin tag measuring 18x9x3 cm on the perineum [5].Canalizo-Almedia et al. reported two patients with giant skin tags on their labia majora measuring 15 cm and 30 cm in diameter [3].
The diagnosis of a skin tag is usually made by its clinical features [3].Buschke-Lowenstein tumor, pedunculated seborrheic keratosis and neurofibromatosis should be included in the differential diagnosis.Electrocauterization and cryotherapy are the treatment  options.Surgical removal is recommended for large lesions, however recurrence may occur [1,2].

A giant skin tag of the scrotum and verruca anogenitalis
In conclusion, giant skin tags have been reported on labium majus, penis and perineum previously.However, a 6x4x3 cm giant skin tag on the scrotal skin is the first case report in the English medical literature to the best of our knowledge.Moreover, the patient had both a giant skin tag and verruca anogenitalis on the scrotal skin.These findings support that HPV infection may play role in the etiology of skin tags.

Figure 1 :
Figure 1: A hyperpigmented, erythematous, polypoid mass measuring 6x4x3 cm in size and a hyperkeratotic, skin colored, small papule on the left scrotal skin (white arrows).

Figure 2 :
Figure 2: a) A polypoid mass hanging from the left scrotal skin with a peduncle and a hyperkeratotic, small papule above the giant lesion (white arrows) b) The specimen after surgical excision.
b a