Skin Tag Removal

  • Review the patient’s chart for potential complicating factors, e.g. keloid scars, bleeding disorders (e.g. von Willebrand), previous surgical complications, allergies to betadine/latex, current antiplatelet/anticoagulant medications, etc.

  • Set-up the procedure room by ensuring all necessary materials are present and easily accessible. Prepare for both cryosurgery and electrocautery.

  • Materials: Consent form, gloves, skin marker, six inch cotton swabs, container with liquid nitrogen, betadine, alcohol swab, lidocaine 2% with epinephrine, 3 mL syringe, 16 gauge needle (gray), 20 gauge needle (pink), blunt dermal Bovie tip, Bovie electrosurgery device, flat forceps, specimen container with formalin, 4x4 gauze, aluminum chloride 10% solution, bacitracin, adhesive bandage.

  • Identify the lesion(s) to be removed and appropriate surgical method:

    • Multiple lesions: Place a mark beside each target lesion with a skin marker. Measure and record each lesions’ size and location. Do not remove more than 15 lesions for safety and billing purposes (see notes).

    • ONLY use cryosurgery for unequivocally benign lesions. Do NOT use cryosurgery for lesions with asymmetry, uneven borders, pigmentation, diameter ≥ 6 mm, and/or recent change in appearance.

    • Any lesions with concerning characteristics (see italics above) should be removed with electrocautery and sent for biopsy. Label specimen container(s) and place tissue biopsy order(s) before proceeding.

  • Consent the patient for the procedure. Discuss risk for pain, bleeding, infection, injury to surrounding tissue, temporary swelling, permanent scarring. Inform patient that reactive scaring may may produce a lesion larger than the one removed. Inform the patient that multiple rounds of cryotherapy may be required to remove a lesion.

Cryosurgery Method

  • Submerse the cotton swabs in liquid nitrogen.

  • Place the cotton swabs on either side to of the lesion peduncle and compress until it frosts. Repeat 2-3 times.

  • Complete a procedure note and bill the procedure (see notes).

Electrocautery Method

  • Identify the lesion to be removed.

  • Clean area with betadine. Do NOT use alcohol swabs as alcohol can ignite and burn the patient.

  • Prepare anesthetic (lidocaine 2% with epinephrine): Clean bottle top with alcohol swab. Insert 3 mL syringe with 16 gauge needle and fill syringe. Remove the 16 gauge needle (discard in sharp bin) and attach a 25 gauge needle. Insert the syringe bevel-deep at the lesion edge. Draw back and insure no blood enters the needle before injecting to form a wheel under the lesion. Wait 7 minutes for lidocaine and epinephrine to take effect.

  • Affix a blunt dermal tip to the Bovie pencil. Turn on the electrosurgery generator and set the device to 3.0.

  • Pinch the skin tag with forceps to ensure appropriate anesthesia. Use the forceps to lift the lesion away from the skin. Use the Bovie pencil to remove the lesion.

  • Place the lesion in a formalin specimen container.

  • Have 4x4 gauze and aluminum chloride 10% solution available for hemostasis if necessary. Alternatively, increase the Bovie to 6.0 to use it as electrocautery.

  • Cover the surgical site with bacitracin and an adhesive bandage.

  • Verify the tissue biopsy is labeled and give it to the appropriate staff member.

  • Complete a procedure note, log the biopsy, and bill the procedure (see notes).

  • Call the patient once biopsy results are received and document the conversation.

Notes

  • Local anesthesia

    • Do NOT apply lidocaine with epinephrine to peripheral appendages, e.g. fingers, toes, penis.

    • Conservatively, the maximum recommended topical lidocaine dose is 4.5 mg/kg per session, not to exceed 300 mg. (The 300 mg limit applies to patients ≥ 67 kg.) For 2% lidocaine (20 mg lidocaine per mL), 15 mL solution contains 300 mg lidocaine. Reserving up to 1 mL topical anesthetic per lesion, this results in a maximum of 15 lesions removed per session. Fifteen is also the maximum number of lesions that can be billed under CPT 11200 (see below).

  • Bill each skin tag removed (up to 15 lesions) as 11200. For example, removal of 5 skin tags will be billed as 11200, 11200, 11200, 11200, 11200.