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Surgical Pearl: A rapid technique for destroying small skin tags and filiform warts

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Surgical Pearl: A rapid technique for destroying small skin tags and filiform warts.
Herbert P Goodheart MD
Dermatology Online Journal 9 (5): 34

Department of Dermatology, Mount Sinai College of Medicine, New York, New York


Thin, small skin tags are easily removed by snipping them off at their base using an iris or Gradle scissors. Alternatively, many dermatologists prefer to use electrocautery or liquid nitrogen to destroy them, with or without prior local anesthesia. Filiform verrucae may be treated in a similar fashion; however, local anesthesia is generally required.

Following scissors-snip excisions, local pressure or a topical agent such as aluminum chloride or Monsel's solution (ferric subsulfate) is often necessary to obtain hemostasis. Both agents may cause a stinging or burning reaction unless the area was pre-anesthetized. After completion, the procedure is followed by the time-consuming application of one or numerous, small, surgical dressings e.g., Band-Aids. Electrocautery, especially when used on bulkier lesions, can be painful unless local anesthesia is used, which in itself is traumatic for many patients. Treatment with liquid nitrogen, whether applied with a cotton-tipped applicator or sprayed with a Cryogun, can result in tissue damage (e.g., blisters) beyond the intended target.


Figure 1 Figure 2
This hemostat immersed in a paper drinking cup of shallow liquid nitrogen is being prepared while another hemostat is being used. The cup may be hand-held with the operator's free hand, held by an assistant, or secured in a cup holder.
Here an axillary skin tag is treated with liquid nitrogen applied with a needle holder.

A method providing rapid and painless treatment for small skin tags is to dip a hemostat, a nontoothed forceps, or a needle holder into liquid nitrogen for 15 seconds, and then to use that instrument to gently grasp the stalk of each skin tag for about 10 seconds. Care is taken to not touch the surrounding skin. The frozen tips of the instrument can treat up to about 10 lesions after being dipped in the liquid nitrogen.

If a hinged instrument (such as a hemostat or needle-holder) is used, the level of liquid nitrogen (transferred to a paper or Styrofoam drinking cup that can be either hand-held or secured in a cup holder), should be shallow enough so that the hinge does not freeze. A second instrument can be freezing in the liquid nitrogen while the other is being used. I have not noted any rusting, corrosion, or performance problems with of any of the aforementioned instruments that I have used multiple times for the past 2 years.

The patient experiences only a very mild sting. The procedure results in little or no collateral damage to the skin, just a narrow rim of erythema. Multiple lesions can be treated by this method. No hemostasis or dressings are necessary. The frozen tag will be shed in approximately 7 to 10 days.

Figure 3 Figure 4
Here a pedunculated fibroepithelioma is being gently frozen with a needle holder.

Figure 5
This upper eyelid small skin tag can be treated with liquid nitrogen in a similar manner. There is no dripping, so the patient is able to lie down during the procedure.

This technique is especially useful for small pedunculated tags that hang on the eyelids (Fig. 4). In fact, the patient can lie down during the procedure since there is no dripping of the liquid nitrogen from the frozen instrument; whereas cotton-tipped application of liquid nitrogen can drip on the patient on unintended areas. Bulkier lesions are best treated with conventional methods.

Another setting is for the treatment filiform facial warts, particularly in apprehensive children (figs. 6 and 7). As with skin tags, the frozen wart is generally shed in 7 to 10 days; however, as with most warts, retreatment is often necessary.

Figure 6 Figure 7
This 4-year-old child was very cooperative and allowed me to freeze these filiform warts repeatedly with a hemostat. She only experienced a mild stinging sensation. Resolution of the wart required 3 return visits.


1. Dawber, R, Colver, G, Jackson, A, Pringle, F. Cutaneous Cryosurgery, Principles and Clinical Practice, 2nd ed. London: Mosby; 1997. p. 56-57.

2. Goodheart HP. Goodheart's Photoguide of Common Skin Disorders: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott, Williams, and Wilkins; 2003. p. 327-8.

3. Kuwahara RT, Huber JD, Ray SH. Surgical pearl: forceps method for freezing benign lesion. J Am Acad Dermatol. 2000 Aug;43(2 Pt 1):306-7. No abstract available. PubMed

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