Consultations & Comments: Do You Recognize This Lesion?

Does this look like a skin tag? It was present on the neck of a neonate, on the mid-lateral right side. What are other diagnostic possibilities?

----Mahmoud Omari, MD

The lesion depicted is not likely to be a skin tag, which appears almost exclusively in older adults. Multiple skin tags result from a hereditary predisposition and have been linked to malignant polyposis of the colon. In this infant, however, such a lesion located on the mid-lateral neck would most likely be a branchial cleft anomaly. Such developmental defects occur from incomplete closure of embryonic clefts, with trapped tissue remaining behind in the neck. Defects can be associated with the first, second (most common), and third branchial clefts and appear in an increasingly caudal location in the neck.

Although most are deeply situated cystic masses, branchial cleft anomalies may present in a more superficial form, as illustrated here. Although seemingly limited to the skin and soft tissue, such defects can be attached to vital neurologic and vascular structures. Therefore, some type of imaging is appropriate to evaluate the mass before surgical removal. A CT scan may suffice for some, but MRI gives better definition with smaller lesions.

I would recommend referral to a pediatric otorhinolaryngologist experienced in the removal of branchial cleft anomalies. The differential diagnosis of this lesion also includes a congenital dermoid cyst: surgical extirpation is the preferred treatment for this entity as well.

----Ted Rosen, MD Professor of Dermatology Baylor College of Medicine Houston