Photo Rounds

Longstanding neck growths

A 42-year-old woman presented to her family physician (FP) and asked to have some skin tags removed from her neck. She said that the skin tags began appearing in her late 20s and that her brother also had them. She denied any seizures and indicated that she tried to stay away from doctors.

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After palpating the soft growths and noting more than 5 café au lait macules and axillary freckling, the FP made a diagnosis of neurofibromatosis type 1. Neurofibromatosis type 1 is an autosomal dominant genetic condition that leads to the development of tumors along the nerves in the skin, brain, and other parts of the body. The FP explained to the patient that these were neurofibromas—not skin tags—and that there can be serious health issues associated with neurofibromatosis, including tumors of the eye (optic gliomas) and nervous system. The patient was willing to see an ophthalmologist, but still wanted some of the growths removed.

The FP scheduled an appointment to remove some of the neurofibromas. He explained to the patient that he would not have time to remove them all but could take care of the ones that bothered her the most. At the patient’s next scheduled appointment, the FP removed the largest neurofibroma on the anterior neck using an elliptical excision at the base of the neurofibroma and sutured it closed using 4-0 nylon as a running suture. The FP sent the first excision to Pathology. (See a video on how to perform an elliptical excision here.)

One week later, the patient returned to have the sutures removed. The pathology report had come back and it confirmed the diagnosis of neurofibromas. The FP planned to remove some of the small neurofibromas using punch excision in the future. At follow-up one month later, the patient was happy with how her skin had healed. Her ophthalmology evaluation did not show any serious tumors.

Photos and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Smith AM. Skin tags. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013: 922-925.

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