Susana Correia de Oliveira1, Sara Rodrigues2, Bruno Arroja3, Teresa Pontes2.
1Pediatrics Department, Senhora da Oliveira Hospital, Guimarães, Portugal,
2Pediatrics Department, Braga Hospital, Braga, Portugal,
3Gastroenterology Department, Braga Hospital, Braga, Portugal.
ADDRESS FOR CORRESPONDENCE
Susana Correia de Oliveira, Pediatrics Department, Senhora da Oliveira Hospital, Rua dos Cutileiros, nº114, Creixomil, 4835-044.
Email: susanafco@hotmail.com | | Abstract | Introduction: Crohn's Disease, an inflammatory bowel disease often associated with perianal complications, poses unique challenges in adolescents, a critical period where risky behaviors are frequent.
Case Report: A seventeen-year-old female was referred to a hospital consultation with suspected perianal condylomas. The patient’s history and a careful HEEADSSS assessment excluded a history of risky behaviors and prompted further investigation. Physical examination revealed three pedunculated “elephant ear” perianal pink lesions alongside other smaller similar lesions that, along with the clinical history of looser stool, led to the diagnostic suspicion of Crohn’s Disease, prompting the performance of a colonoscopy and confirming the diagnosis.
Discussion: Recognition of perianal skin tags as a diagnosis clue to Crohn’ Disease is vital, as they may mimic other conditions. Excision is discouraged and treatment focuses on managing intestinal disease. This case emphasizes the importance of disseminating knowledge about CD's varied presentations to facilitate early diagnosis and intervention. | | | | Keywords | | diagnosis, perianal skin tags, pediatric crohn’s disease. | | | | Introduction | | Crohn's Disease is an inflammatory bowel disease that frequently complicates with perianal disease. Given that adolescence is a critical period in life with, not only personal development and maturation, but also a time of experimentation and, consequently, a period highly propitious to risky behaviors, it is of the utmost importance to differentially diagnose anorectal pathology from sexually transmitted infections during this age range. | | | | Case Report | A seventeen-year old female patient was referred to a specialized adolescent hospital consultation for suspected perianal condylomas. As relevant personal history she had a premature birth at 35 weeks of gestation, a prenatal diagnosis of situs inversus and a complete national vaccination program, including three doses of human papillomavirus vaccine. Personal history was otherwise unremarkable, as was family history.
The perianal lesions appeared one year prior to medical evaluation and increased in size and number and they weren’t painful. A careful HEEADSSS assessment was performed and revealed she lived in a healthy family environment, had no boyfriend and had no history of risk behaviors as she denied sexual activity or substance or alcohol abuse. There were no concerns for sexual abuse nor history of human papillomavirus infection. The remaining assessment did not reveal any relevant information for the case. After questioning, she reported a history of softer stool with no mucus or blood in the last few months along with an increased number of defecations (three to four a day for a normal of one to two), that was already medicated with probiotic without improvement. She also had a history of weight loss that was not valued by herself or her family as she was trying to be careful with her diet. She denied fever, vomiting, nausea, constipation, abdominal pain, arthritis, joint pain, genital lesions or oral ulcers. There was no known history of contact with people with tuberculosis.
On physical examination she had a good overall condition, she measured 153,1 cm, had a BMI of 19,4 kg/m2 and pubertal development was Tanner 5. Physical examination of the perianal region revealed three pedunculated “elephant ear”, non tender, perianal pink lesions alongside other smaller similar lesions (Figure 1). Digital rectal examination was negative for palpable masses in the anal canal. Laboratory evaluation revealed a microcytic anemia (Hgb 8,5 g/dL, MCV 65 fL) with associated iron deficiency and elevated CRP 30 mg/L. Fecal calprotectin was 2050 mcg/g. Initial study did not show other significant alterations and tuberculosis screening was negative. She was referred to a gastroenterology consultation and performed a colonoscopy revealing ileitis and numerous ulcers in the ileum. Crohn's Disease (CD) A1L1B1p was diagnosed and the patient was subsequently started on biologic therapy and iron supplementation.
Figure 1. “Elephant ear” skin tags in a 17-year-old adolescent girl leading to the diagnosis of Crohn’s Disease.
| | | | Discussion | In CD perianal skin tags may precede intestinal disease in months or years.1,2 A 2020 study showed that perianal skin tags are present at diagnosis in over 15% of patients and concluded that skin tags were present a median of six years before CD diagnosis.3 Excision of these skin tags is generally contraindicated because of poor wound healing and increased risk of perianal complications.1,4 Treatment should be directed at treating the intestinal disease, as perianal skin tags may persist over the course of CD, independently of the activity of intestinal disease.5,6
As they may simulate other perianal diseases, like condylomas or hemorrhoids, a thorough history should be taken, especially in teenagers who are more prone for risky sexual behaviors. Tags from CD differ from other diseases as they are usually painless and rarely associated with bleeding during defecation. They have been described as “elephant ears” for their flesh coloration hypertrophic, raised and smooth appearance.3,7,8 Learning to differentiate these lesions may prevent erroneous investigations for sexually transmitted infections or other perianal disease that may cause unwarranted trauma for both the patient and their family.1
Given that skin tags may be the first and only sign of CD for years it is crucial to disseminate this form of early presentation of Crohn's disease among physicians from different specialties, such as family doctors and pediatricians, as diagnosing this disease earlier may allow for an earlier diagnosis and treatment in a preclinical phase, improving quality of life and preventing late complications.3,7,8 | | | | Conclusion | | A perianal pathology in adolescence raises doubts about the possibility of risky behaviors, and clinical history should always be clarified with a focus on the HEEADSSS approach. However, medical causes for perianal pathology should not be overlooked, regardless of the patient's age. | | | | Compliance with Ethical Standards | | Funding None | | | | Conflict of Interest None | | |
- Bellou O, Chrysikos D, Schoinohoriti O, et al.: Perianal skin tags revealing asymptomatic crohn's disease in a 12-year-old child with Growth Impairment: A case report. Cureus. 2023, 15(4):e37513. 10.7759/cureus.37513. [CrossRef]
- Pogacnik JS, Salgado G: Perianal crohn's disease. Clin Colon Rectal Surg.. 2019, 32:377-85. 10.1055/s-0039-1687834. [CrossRef]
- Korelitz B, Schneider J, Swaminath A, et al.: Observations on the Neglect of Anal Skin Tags as an Early Marker of Crohn's Disease in Children. Pract. Gastroenterol. 2020, XLIV:12-17.
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- Triantafillidis JK, Emmanouilidis A, Nicolakis D, et al.: Clinical Patterns of Crohn's Disease in Greece: A Follow-Up Study of 155 Cases. Digestion. 2000, 61(2):121-128. 10.1159/000007744. [CrossRef]
- Funayama Y, Sasaki I, Imamura M, et al.: Surgical management of perianal lesions in Crohn's disease. Nippon Geka Gakkai Zasshi. 1987, 88:562-568.
- Chang B, Chan A, Yeh J: Anal Skin Tags Mistaken for Hemorrhoids in Early Crohn's Disease. UCLA Health. 2022, 26:1-2.
- Peyrin-Biroulet L, Sandborn W, Sands BE, et al.: Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE). Am J Gastroenterol. 2015, 11:1324-1338. 10.1038/ajg.2015.233. [CrossRef]
DOI: https://doi.org/10.7199/ped.oncall.2025.69
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| Cite this article as: | | Oliveira S C d, Rodrigues S, Arroja B, Pontes T. Perianal Skin Tags as a Diagnosis Clue to Crohn's Disease. Pediatr Oncall J. 2024 Jan 29. doi: 10.7199/ped.oncall.2025.69 |
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