Acanthosis nigricans

Systematic review of topical, laser, and oral treatments in acanthosis nigricans clinical trials

Acanthosis nigricans (AN), with an estimated prevalence of 19.4% in the U.S., presents as hyperpigmented, velvety plaques in intertriginous regions. Acanthosis Nigricans negatively affects psychological well-being and particularly impacts skin of color individuals. Addressing the underlying cause of acanthosis nigricans, as current guidelines recommend, is often challenging. This highlights the importance of skin directed treatment for acanthosis nigricans. This systematic review evaluated topical, laser, and oral treatments for acanthosis nigricans and provides evidence-based recommendations for clinical use. Adhering to PRISMA guidelines, we evaluated 19 clinical trials investigating topical, oral, and laser interventions for acanthosis nigricans. Oxford Centre for Evidence-Based Medicine guidelines were used to make clinical recommendations. We strongly recommend topical tretinoin (grade A) and endorse the appropriate use of adapalene gel, urea cream, and fractional carbon dioxide laser therapy (grade B). Further research is essential to enhance our understanding of alternative treatments to determine additional evidence-based recommendations. This review aims to guide clinicians in managing acanthosis nigricans, especially when direct treatment of underlying conditions is impractical.

Acanthosis nigricans - a potentially useful clue to the presence of significant occult disease at autopsy

A 19-year-old male was found dead in his apartment. At autopsy he was morbidly obese (Body mass index; BMI - 40.5) with multiple areas of velvety pigmented thickening of the skin in folds around the neck, in the axillae, in the inframammary regions, over the anterior waistline and groin regions and over the dorsal aspects of the feet. These had the typical appearance of acanthosis nigricans. Internal examination revealed aspiration of gastric contents into the airways. Vitreous humour biochemistry showed markedly elevated levels of both glucose (62.9 mmol/L) and β-hydroxybutyrate (13.54 mmol/L). Death was, therefore, due to aspiration pneumonia complicating diabetic ketoacidosis on a background of morbid obesity. The initial indicator of underlying diabetes, in conjunction with obesity had been acanthosis nigricans.

The Metabolic Syndrome, a Human Disease

This review focuses on the question of metabolic syndrome (MS) being a complex, but essentially monophyletic, galaxy of associated diseases/disorders, or just a syndrome of related but rather independent pathologies. The human nature of MS (its exceptionality in Nature and its close interdependence with human action and evolution) is presented and discussed. The text also describes the close interdependence of its components, with special emphasis on the description of their interrelations (including their syndromic development and recruitment), as well as their consequences upon energy handling and partition. The main theories on MS's origin and development are presented in relation to hepatic steatosis, type 2 diabetes, and obesity, but encompass most of the MS components described so far. The differential effects of sex and its biological consequences are considered under the light of human social needs and evolution, which are also directly related to MS epidemiology, severity, and relations with senescence. The triggering and maintenance factors of MS are discussed, with especial emphasis on inflammation, a complex process affecting different levels of organization and which is a critical element for MS development. Inflammation is also related to the operation of connective tissue (including the adipose organ) and the widely studied and acknowledged influence of diet. The role of diet composition, including the transcendence of the anaplerotic maintenance of the Krebs cycle from dietary amino acid supply (and its timing), is developed in the context of testosterone and β-estradiol control of the insulin-glycaemia hepatic core system of carbohydrate-triacylglycerol energy handling. The high probability of MS acting as a unique complex biological control system (essentially monophyletic) is presented, together with additional perspectives/considerations on the treatment of this 'very' human disease.

Updates on the dermatopathology of pregnancy-associated skin conditions

Pathologists provide valuable input in the dermatological care of pregnant patients in various contexts. This article provides dermatopathology updates on cutaneous changes associated with pregnancy, organized based on the following classification system: physiological skin changes in pregnancy, specific dermatoses of pregnancy, dermatoses modified in pregnancy, and skin neoplasms in pregnancy. Awareness of the impact of pregnancy on the skin by pathologists is important, as this is an opportunity to contribute to diagnostic precision in this patient population.

Case Report: Paraneoplastic psoriasis in thymic carcinoma

Thymic carcinomas are exceedingly rare and very aggressive malignancies of the anterior mediastinum. While thymomas exhibit a high association with paraneoplastic syndromes, these phenomena are a rarity in thymic carcinomas. In general, acanthotic syndromes such as acroceratosis neoplastica and acanthosis nigricans maligna are commonly observed as paraneoplastic phenomena in patients with carcinomas. In contrast, psoriasis vulgaris, another acanthotic disease, rarely occurs as a paraneoplasia. We report the case of a 36-year-old patient with progressive thymic carcinoma (undifferentiated carcinoma, T3N2M1a) and paraneoplastic psoriasis occurring ten months before the initial diagnosis of the carcinoma. Over the course of the disease, new psoriatic flares heralded relapse or progression of the carcinoma. To our knowledge, this is the first reported case of paraneoplastic psoriasis in thymic carcinoma.

Skin manifestations of pancreatic diseases

Although symptoms of pancreatic diseases such as pancreatitis, acute and chronic and, carcinoma of the pancreas are mainly gastrointestinal in nature, the extra-pancreatic symptoms are also important. These include skin symptoms, such as pancreatic panniculitis, acanthosis nigricans, livedo reticularis, necrolytic migratory erythema, cutaneous signs of hemorrhage, as in persons with severe acute pancreatitis, or the finding of cutaneous metastases of pancreatic carcinoma, which may be a sign of advanced disease. The pancreas is therefore one of those organs for which diagnosis and therapy are often multidisciplinary. In this review article, we summarize current knowledge of the possible skin manifestations of pancreatic disorders.

Type 2 diabetes in children and adolescents: distinct characteristics and evidence-based management

PURPOSE

Since the dramatic rise of obesity prevalence in childhood and adolescence has contributed to increased rates of type 2 diabetes (T2D) in youth, we sought to explore current evidence-based management options for pediatric T2D patients.

METHODS

A comprehensive literature search was performed for studies of T2D in childhood and adolescence until September 2021.

RESULTS

Special pathophysiological and diagnostic characteristics of T2D in this age are presented, while the main focus of the article is on management. Lifestyle interventions with healthy diet and exercise are of great importance for the treatment of T2D in children and adolescents. Metformin and insulin remain the traditional therapeutical means, while liraglutide recently gained indication for children older than 10 years both in USA and Europe. Data on the use, efficacy, safety and therapeutic considerations of other pharmacological treatments in children and adolescents with T2D are critically discussed.

CONCLUSION

Although many new and promising therapeutic strategies have been introduced during recent years for the management of T2D in adults, available therapeutic options for the management of pediatric T2D remain limited.

Cancer

Malignancy is the second leading cause of death in the United States, following heart disease. In most cancers, early detection is one of the most important factors in determining prognosis. As clinicians it is therefore important to be aware of potential clues of underlying malignancy on physical examination. Given the wide range of malignancies, and the heterogeneous nature of their presentations, this article is by no means exhaustive. Instead, it discusses in depth some of the more frequently encountered physical examination findings that may suggest malignancy. Specifically, it covers lymphadenopathy, cutaneous findings related to various cancers, and malignancy related thrombosis.

Severe Quantitative Scale of Acanthosis Nigricans in Neck is Associated with Abdominal Obesity, HOMA-IR, and Hyperlipidemia in Obese Children from Mexico City: A Cross-Sectional Study

Background. Acanthosis nigricans (AN) is a clinical sign that commonly occurs in obesity; however, its specificity and sensitivity have been controversial. It is unknown if AN severity degree can be a useful marker for cardiometabolic disorders screening. We suggest that the stratified analysis of AN severity degree in neck by Burke’s scale could be a useful tool in the screening of cardiometabolic alterations in obese children. Objective. The aim of this study was the association of AN severity degree in neck by Burke’s scale with anthropometric, biochemical, and inflammatory parameters in obese school-age children from Mexico City. Methods. A cross-sectional study was conducted, including 95 obese school-age children stratified by AN severity degree in neck by Burke’s scale. Anthropometric and fasting biochemical measurements were determined. Variables were compared by x2 test for frequencies and one-way ANOVA with Bonferroni posttest for continuous variables. Linear regression analysis adjusted by gender, BMI, and age was performed to evaluate the association between AN severity degree and cardiometabolic alterations. Statistical significance was set at $p<0.05$ . Results. As AN severity degree in neck by Burke’s scale increased, diastolic blood pressure ( $p=0.001$ ) and triglycerides ( $p=0.02$ ) significantly increased and adiponectin significantly decreased ( $p=0.02$ ). Positive associations between grade 3 AN and waist circumference, HOMA-IR, triglycerides, total cholesterol, and LDL cholesterol were observed. Conclusion. Our findings could be used to identify an easier clinical tool to prevent obesity progression and its complications in pediatrics. There are no similar studies.

Cutaneous Manifestations of Diabetes

Diabetes mellitus is a significant worldwide health concern and cutaneous manifestations are common. This review describes characteristic skin findings of diabetes, general skin findings related to diabetes, and findings related to diabetes treatment with a focus on clinical presentation, diagnosis, pathophysiology, epidemiology, and treatment. As the prevalence of diabetes continues to rise, cutaneous manifestations of diabetes mellitus likely will be encountered more frequently by physicians in all disciplines including dermatologists and primary care physicians. Accordingly, knowledge regarding the prevention, diagnosis, and management of cutaneous manifestations is an important aspect in the care of patients with diabetes.

Acanthosis nigricans: A review

BACKGROUND

Acanthosis nigricans (AN) is a cutaneous disorder characterized by symmetric velvety hyperpigmented plaques on intertriginous areas like axilla, neck, inframammary, and groin.

AIMS

To summarize the pathophysiology and classification of AN, provide an update of diagnostic testing strategies, and describe the current therapeutic options described so far in the literature for this disease.

METHODS

A comprehensive english language literature search across multiple databases (PubMed, EMBASE, MEDLINE, and Cochrane) for keywords (alone and in combination) was performed. MeSH as well as non-MeSH terms such as "acanthosis nigricans," "classification," "pathophysiology," "diagnosis," "treatment," "topical drugs," "systemic drugs," "chemical peeling," and "lasers" were taken into consideration.

RESULTS

The pathophysiology of AN revolves around a multifactorial stimulation of proliferation of epidermal keratinocytes and dermal fibroblasts. Various types of AN include benign, obesity-associated, syndromic, malignant, acral, unilateral, medication-induced, and mixed-type. Homeostasis model assessment-insulin resistance (HOMA-IR) is a good tool for assessment of insulin resistance. Management involves general measures (weight reduction and addressing the underlying cause, if any), topical drugs (retinoids, vitamin D analogs, and keratolytics), oral drugs (retinoids and insulin sensitizers), chemical peels (trichloroacetic acid), and lasers (Long pulsed alexandrite, fractional 1550-nm erbium fiber, and CO₂ ).

CONCLUSION

Acanthosis nigricans is a treatable condition; however, complete cure and disappearance of lesions are difficult to achieve. Weight reduction is the most scientific and practical management strategy. Long-term studies and further research is warranted in the pathophysiology and treatment of this common condition.

Malignant Acanthosis Nigricans with Recurrent Bladder Cancer: A Case Report and Review of Literature

Acanthosis nigricans (AN) is a rare cutaneous condition that may be a manifestation of certain endocrinological or autoimmune diseases, as well as a potential marker for underlying undiagnosed cancer. AN is classified as either benign or malignant based on its clinical associations. Malignant acanthosis nigricans (MAN), which tends to be extensive and develops rapidly, is considered to be a paraneoplastic syndrome associated with advanced cancer, commonly accompanied by intra-abdominal malignancies. Bladder cancer with AN concomitant with tripe palms (TP) and/or mucosal involvement is relatively rare and, to our knowledge, only seven cases of AN with bladder cancer have been reported in the English literature. However, to date, there have been no reports of bladder cancer with AN concomitant with TP, skin and mucosal involvement. Here, we present a case of a 71-year-old male diagnosed with AN coexisting with recurrent bladder cancer and simultaneous TP and oral AN. In addition, we provide a brief review of the available literature on this topic. Early recognition of skin features associated with internal malignancies provides an opportunity for early diagnosis, treatment of the internal malignancy and monitoring of tumor recurrence.

Drug-induced acanthosis nigricans: A systematic review and new classification

Drug-induced acanthosis nigricans is an uncommon subtype of acanthosis nigricans and the data on this topic is not well understood by clinicians as it is presently limited in the literature. Previous reports of drug-induced acanthosis nigricans have simply consisted of a list of drugs possibly implicated in causing acanthosis nigricans. Several drugs listed are based on single case reports without biopsy confirmation, report of clearing on stopping the drug or reporting on whether acanthosis nigricans recurred with drug rechallenge. A comprehensive literature search was conducted using PubMed, EMBASE(Ovid), Cochrane Library, Scopus, and Web of Science electronic databases. The authors screened the initial result of the search strategy by title and abstract using the following inclusion criteria: eligible studies included those with patients who developed acanthosis nigricans secondary to a drug. This study is the first to comprehensively review the drugs that have been implicated in the development of acanthosis nigricans. A total of 38 studies were included in the systematic review, and a total of 13 acanthosis nigricans inducing drugs were identified. Nicotinic acid and insulin were the two most significant drugs that were reported to cause acanthosis nigricans. By using the results of this study, we created a revised classification system of drug-induced acanthosis nigricans which can be used as a concise framework for clinicians to refer to.

Chronic Systemic Inflammatory Skin Disease as a Risk Factor for Cardiovascular Disease

Chronic systemic skin disease and cardiovascular disease are multisystem disorders which have been associated with each other for centuries. Recent research has strengthened this association, particularly in systemic inflammatory disease. Here we explore the current literature on psoriasis, hidradenitis suppurativa, lupus erythematosus, acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. Psoriasis is a chronic inflammatory disorder that has been labeled as a risk-modifier for hyperlipidemia and coronary artery disease by the American College of Cardiology ACC lipid guidelines. Cardiovascular disease is also found at a significantly higher rate in patients with hidradenitis suppurativa and lupus erythematosus. Some associations have even been noted between cardiovascular disease and acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. While many of these associations have been attributed to a shared underlying disease process such as chronic systemic inflammation and shared underlying risk factors, these dermatologic manifestations can help to identify patients at higher risk for cardiovascular disease.

Relationship of acanthosis nigricans with metabolic syndrome in obese children

OBJECTIVES

Acanthosis nigricans is a skin symptom in obesity that helps to identify patients at high risk for dyslipidemia, hypertension, insulin resistance, and diabetes. It is the most important complication of obesity in metabolic syndrome. Studies investigating the relationship between acanthosis nigricans and metabolic syndrome in obese children are insufficient. In our study, the relationship of acanthosis nigricans and metabolic syndrome was evaluated in children.

METHODS

Obese children aged between 6 and 18 years old, who were examined in the pediatric endocrinology outpatient clinic, were included. The patients' anthropometric measurements and laboratory results were recorded. Modified IDF (International Diabetes Federation) criteria for children were used in metabolic syndrome classification.

RESULTS

A hundred and forty-eight obese children were evaluated. The mean age of the cases was 11.91 ± 2.94 years old. Of the cases, 56.1% were female (n=83) 43.9% (n=65) were male. In 39.9% (n=59) of cases, acanthosis nigricans was determined. Acanthosis nigricans was mostly located in the axillary area (27.1%) and the neck (16.9%). In 55.9% of the cases, it was located in more than one area. The relation of regionally detected acanthosis nigricans and metabolic syndrome was not significant (p=0.291). Metabolic syndrome was detected in 14% of 136 patients according to IDF criteria. Acanthosis nigricans and metabolic syndrome combination was present in 27.7%; however, 6.7% of the metabolic syndrome patients did not have acanthosis nigricans. There was a strong relation between metabolic syndrome and the presence of acanthosis nigricans (p=0.003).

CONCLUSIONS

In our study, a correlation between acanthosis nigricans and metabolic syndrome was detected. Acanthosis nigricans is a skin sign that can be easily detected by clinician. It is an important and easy-to-detect dermatosis that helps determine patients at risk of metabolic syndrome in obese children.

Malignant acanthosis nigricans with Leser–Trélat sign and tripe palms: A case report

BACKGROUND

Acanthosis nigricans (AN), Leser–Trélat sign, and tripe palm are all skin diseases. To date, reports of these appearing as a paraneoplastic syndrome in a gastric cancer patient are quite rare.

CASE SUMMARY

We report the case of a 61-year-old man with darkened skin color in the face and torso with no obvious inducement after 1 year of treatment for Riehl’s melanosis. He had 40 brown maculopapular eruptions on his face and the top of his head with obvious itching. Papillary wart-like hyperkeratosis with dark brown pigmentation was also observed on both sides of the areola. He had papilloma-like lesions on the face, around the orbit, and on the neck. His bilateral palms had small, smooth, papillary projections with millet-like appearance. Histopathological examination of the skin showed that the patient was suffering from AN, tripe palms, and Leser–Trélat sign. Gastroscopy showed the patient’s cardia was affected, and pathological biopsy revealed that he had moderate-to-poorly differentiated adenocarcinoma. Computed tomography test results showed that his cardia wall had thickened. Based on these histological and skin characteristics, the patient was diagnosed with gastric cancer with AN, tripe palms, and Leser–Trélat sign.

CONCLUSION

Researchers should follow up on patients with malignant AN, Leser–Trélat sign, and tripe palms.

Introduction of a novel quantitative scoring system for acanthosis nigricans and its validation in a pilot study

Inconsistent data exist regarding the diagnostic value of acanthosis nigricans (AN) or skin tags as clinical markers for obesity or diabetes. In an outpatient department-based prospective study, we designed a scoring for AN severity (SCANS) to evaluate AN and skin tags, their correlation with obesity or diabetes. Quantification of AN in six anatomic sites, in consideration of the affected skin surface areas, texture changes, number of skin tags, leads to a total severity score between 0 and 46. Among 336 adult patients (aged ≥18 years) with AN, a higher BMI was associated with AN (r = 0.299, P < .001), but not with diabetes (P = .43), as compared with 243 age- and sex-matched controls without AN. Among nondiabetics, AN scores were significantly correlated with waist circumference (r = 0.131, P = .024) and total cholesterol levels (r = 0.155, P = .04). Skin tags alone in the absence of AN were not associated with obesity (P = .333) or diabetes (P = .164). The total AN scores were positively correlated with the presence of skin tags (r = 0.132, P < .001), and the involvement of anterior neck (r = 0.668, P < .001) and axilla (r = 0.793, P < .001). Knuckles and groins were unaffected in our series. Our results indicate that combination of AN with skin tags can be used as clinical marker for obesity, but not for diabetes. Large-scale studies on patients of different ethnic background are required to further validate our proposed scoring.

Cutaneous Manifestations in Pancreatic Diseases-A Review

Pancreatic pathology, comprising acute and chronic pancreatitis, autoimmune pancreatitis and pancreatic neoplasms, primarily presents with gastrointestinal symptoms and signs; however, it is well recognized that it can also associate a wide range of extra-digestive features. Among these systemic manifestations, cutaneous involvement plays an important role both as a diagnostic clue for the pancreatic disease itself and serving as a prognostic factor for the severity of the condition. Recognition of these cutaneous signs is, however, far from being satisfactory, all the more as some of them are relatively rare. In the current review, we discuss skin involvement in pancreatic diseases, referring to pancreatic panniculitis, cutaneous hemorrhagic manifestations, skin metastasis, acanthosis nigricans, livedo reticularis, necrolytic migratory erythema and cutaneous fistula. We highlight the clinical characteristics, treatment and prognostic value of these lesions. Better awareness among medical specialties other than dermatology is needed for detection of the skin clues associated with pancreatic pathology.

A case of acanthosis nigricans in a HIV-infected patient

Background

To date, very little information is available concerning the relationship between acanthosis nigricans (AN) and infection with human immunodeficiency virus type 1 (HIV-1).

Case presentation

Herein, we report the case of a middle-aged man admitted for fever and progressively worsening dyspnea in the context of an opportunistic pneumonia and firstly diagnosed with acquired immunodeficiency syndrome (AIDS). At the time of diagnosis, physical examination revealed the presence of a palpable, hyperpigmented skin lesion on the left areola with surface desquamation and velvety texture consistent with AN. Of note, the most common primary etiologies related to AN were excluded and the complete regression of the skin lesion was observed once antiretroviral therapy was started.

Conclusion

This is the second report of AN found in patients with AIDS and apparently responsive to prolonged antiretroviral treatment. Possible explanations of this association are still not completely understood, probably related to virus-induced changes in lipid metabolism. Our experience suggests that HIV testing should always be considered in the setting of apparently idiopathic AN.

Acanthosis nigricans in middle-age adults: A highly prevalent and specific clinical sign of insulin resistance

BACKGROUND

Insulin resistance (IR) precedes the diagnosis of many metabolic and non-metabolic illnesses, including type 2 diabetes mellitus (T2DM). Acanthosis nigricans (AN) is a clinical sign associated with IR. However, AN prevalence and diagnostic accuracy in middle-age adults before or at the time of prediabetes/diabetes diagnosis remain uncertain.

METHODS

With the aim to define AN prevalence and diagnostic accuracy, adults between 40 and 60 years of age were consecutively invited to participate in the study. Participants were categorised into one of two main groups: individuals with normoglycaemia (group 1) and hyperglycaemia (group 2 [ie, prediabetes/diabetes]). Demographic, clinical, anthropometric characteristics, homeostasis model assessment of IR, homeostatic model assessment of β-cell function, as well as the presence of AN on the neck, axillae, elbows and knuckles were assessed.

RESULTS

A total of 320 consecutive participants with a mean age of 49.3 years (59.4% women) were included. Overall, AN prevalence was 46.3%, while AN in group 1 and group 2 was 36.3% and 49.6%, respectively (P = .04). The most common affected sites in group 1 (n = 80) were the knuckles (21.2%) and the neck (17.5%), while in group 2 (n = 240), the neck (29.6%) followed by the knuckles (26.7%). The specificity and positive predictive value of AN for IR were 0.85 and 0.86 in group 1 and 0.90 and 0.96 in group 2, respectively.

CONCLUSIONS

In middle-age adults, within the entire spectrum of carbohydrate tolerance, AN is highly prevalent and specific. This finding supports its assessment as a reliable and convenient clinical sign of IR. The understanding of AN behaviour through different carbohydrate tolerance strata, and its different locations, could lead to early detection of individuals at high metabolic risk or help direct a more pathophysiological treatment approach in patients with T2DM.

Acanthosis nigricans in childhood: A cutaneous marker that should not be underestimated, especially in obese children

AIM

The occurrence of acanthosis nigricans (AN) in childhood should not be underestimated since it acts as a cutaneous marker of underlying diseases, such as insulin resistance, endocrinopathy, syndromes and malignancy. The purpose of this review was to highlight the clinical significance of AN in childhood and draw attention to its possible role as early marker of alterations in glucose metabolism in obese children.

METHODS

The Cochrane Library and PubMed databases were searched for papers published in English up to April 2019. Observational studies, case reports and reviews from 1994 to 2019 were included.

RESULTS

Most of the cases of AN are associated with obesity. The prevalence of obesity is rising worldwide and is paralleled by global increases in the prevalence of metabolic syndrome in children. Insulin resistance and AN are closely associated. Evidence indicates that AN is a useful clinical marker for the identification of obese and overweight children and adolescents with insulin resistance who are susceptible to type 2 diabetes mellitus and metabolic syndrome.

CONCLUSION

In clinical practice, the recognition of AN is useful for an early identification of children and adolescents, prone to the insulin-resistant obese phenotype, who could benefit from early interventions.

Genetic and developmental disorders of the oral mucosa: Epidemiology; molecular mechanisms; diagnostic criteria; management

A large number of disorders may affect the oral cavity, including genetic diseases, infections, cancers, blood diseases, skin diseases, endocrine and metabolic disorders, autoimmune and rheumatologic diseases, local lesions, to name a few. Oral mucosa shows a considerable variation in its normal structure and a wide range of conditions may affect it. Such conditions are often harmless or minor and could be primary or secondary to systemic disease. Several of them are quite rare and, hence, the diagnosis is not easy. Clinically, lesions may appear as ulcers, discoloration of the oral mucosa and alterations in size and configuration of oral anatomy. Genetic disorders have specific manifestations and can be caused by a derangement of one or more components of the tissue. Many of them follow the skin or systemic signs of the underlying genetic disease, but in a few cases oral signs could be the first manifestation of the disorder. Among them genodermatoses are prominent. They are inherited disorders characterized by a multisystem involvement. This review describes chondro-ectodermal dysplasia, dyskeratosis congenita, Ehlers-Danlos syndrome, hereditary benign intraepithelial dyskeratosis, keratosis follicularis, lipoid proteinosis, multiple hamartoma syndrome, pachyonychia congenita, Peutz-Jeghers syndrome, tuberous sclerosis and white sponge nevus. Other genetic disorders not included in the genodermatosis group and reported in the present review are: acanthosis nigricans, angio-osteo-hypertrophic syndrome, encephalotrigeminal angiomatosis, familial adenomatous polyposis, focal dermal hypoplasia, focal palmoplantar and oral mucosa hyperkeratosis syndrome, gingival fibromatosis, Maffucci's syndrome, neurofibromatosis (type 1) and oro-facial-digital syndrome (type 1). Disorders during embryonic development might lead to a wide range of abnormalities in the oral cavity; some of them are quite common but of negligible concern, whereas others are rare but serious, affecting not only the oral mucosa, but also other structures of the oral cavity (ie palate, tongue and gingiva). Fordyce's granules, leukoedema, cysts of the oral mucosa in newborns, retrocuspid papilla, geographic tongue, fissured tongue, median rhomboid glossitis, hairy tongue, lingual varices and lingual thyroid nodule are described. This review may help dentists, dental hygienists, but also general internists and pediatricians to diagnose different disorders of the oral mucosa, to understand the pathogenesis and to schedule a treatment plan.

Systemic and Autoimmune Diseases

This article reviews the clinical features of systemic and autoimmune diseases affecting the perianal region and its surrounding integumentary structures.

MORFAN Syndrome: A Rarity but a Reality!

Acanthosis nigricans (AN) describes clinically hyperpigmented skin, which most commonly affects the flexural areas such as axilla, groin and neck. It is usually a benign condition associated with obesity, insulin resistance, and hyperinsulinemia; endocrinopathy; or malignancy, in particular, gastrointestinal adenocarcinoma. It can also occur in association with various genetic syndromes involving various organ systems. Few such known syndromes are Berardinelli-Seip syndrome, Alström syndrome, Leprechaunism, and Bardet-Biedl syndrome. MORFAN syndrome, which associates mild mental retardation, pre- and post-natal overgrowth, remarkable facies and diffuse and widespread AN, is a rare entity.

Acanthosis nigricans as a clinical marker of insulin resistance among overweight adolescents

PURPOSE

Acanthosis nigricans (AN) is a hyperpigmented dermatosis associated with obesity and insulin resistance (IR). There is no consensus whether AN extension scoring offers added value to the clinical estimation of IR. In this study we aimed to assess and score AN using both a short and an extended version of the scale proposed by Burke et al. and analyze the relationships of both versions with hyperinsulinemia and IR.

METHODS

We analyzed data from 139 overweight adolescents (body mass index ≥85th percentile) aged 12-18 with (n=67) or without (n=72) AN who were followed at a pediatric obesity clinic.

RESULTS

Adolescents with AN had higher levels of insulin (d=0.56, P=0.003) and HOMA-IR (d=0.55, P=0.003) compared to those without. Neither the short nor the extended versions of AN scores explained either hyperinsulinemia (β=1.10, P=0.316; β=1.15, P=0.251) or IR (β=1.07, P=0.422; β=1.10, P=0.374). The presence of AN alone predicted hyperinsulinemia and the presence of IR in 7.3% (β=2.68, P=0.008) and 7.1% (β=2.59, P=0.009) of adolescents, respectively.

CONCLUSION

Screening for AN at the neck and axilla is a noninvasive and cost-effective way to identify asymptomatic overweight adolescents with or at risk of developing IR.

Acanthosis Nigricans - A Two-Sided Coin: Consider Metabolic Syndrome and Malignancies!

BACKGROUND

Acanthosis nigricans (AN) is acquired hyperpigmentation of the intertriginous body regions. Histologically, AN is characterised by a thickened stratum corneum and a variable amount of acanthosis. Although benign and rarely symptomatic, AN may be a red flag for underlying pathologies.

CASE PRESENTATION

We analysed our patients with AN and could differentiate three different patterns, that are illustrated by one case report each. The is the benign AN associated with metabolic syndrome including obesity. The second type is the paraneoplastic AN malignancy which is associated with a wider range of malignancies. This type may occur before, after or with the clinical appearance of the malignancy. The third type is relapsing AN after complete remission. We present a patient who had a malignant AN and was treated successfully for his cancer. Years later, however, AN relapsed. In that case in association with the appearance of skin tags. Cancer restaging excluded a tumour relapse. His BMI was 31.2 kg/m², and the diagnosis of benign AN was confirmed.

CONCLUSIONS

The diagnosis of AN remains incomplete without screening for metabolic syndrome and/ or cancer. The combination of AN and skin tags is more often associated with metabolic syndrome. AN may be considered as a red flag for malignancies and the metabolic syndrome.

Acanthosis nigricans: To be or not to be afraid

Acanthosis nigricans (AN), a skin disorder with high prevalence, represents a dermatological condition with esthetic implications, but otherwise mild symptoms. For any clinician, it is in fact the tip of the iceberg, leading him/her to investigate what lies beneath the surface, since AN points to a systemic problem or disease: metabolic disorder (most frequently), endocrine syndrome, medication side effects, malignancy, and genetic factors. Sometimes, it is the first observed sign of a malignancy or of diabetes mellitus, especially in patients with chronic metabolic disorder; therefore, it is not to be taken lightly. The present review summarizes the information in literature regarding the etiopathogenesis of AN. We propose a new classification that aims to better organize the different types of AN, with implications on the extent and urgency of the investigation plan, as well as various therapeutic algorithms. Therapy options are also presented, both systemic treatments that target the underlying disease, and local ones for esthetic reasons.

Signo de Leser Trèlat como forma de presentación de cáncer de pulmón. A propósito de un caso

Se presenta el caso de un paciente de 65 años valorado en el hospital Provincial Docente Arnaldo Miliàn Castro en Santa Clara por presentar manchas color café a nivel de la espalda de rápida aparición en alrededor de 2 meses, que antes no estaban, acompañadas de prurito molesto en ocasiones. Fue tratado por dermatología anteriormente por este motivo con diagnóstico de queratosis seborreica. Llamó la atención el comienzo brusco de esta entidad por lo que se planteó un posible signo de Leser Trèlat y se indicaron varios estudios complementarios y radiológicos. Se realiza biopsia cutánea de dos de las lesiones en la espalda y se concluyen como queratosis seborreicas, se realiza Rx de tórax que arroja imagen nodular sospecha de neoplasia de pulmón que se confirma con biopsia. Este signo cutáneo constituye una dermatosis paraneoplàsica poco frecuente y diagnosticada en nuestro medio. Se asocia a neoplasias del tracto digestivo y respiratorio respectivamente.

Acanthosis nigricans in achondroplasia

Acanthosis nigricans (AN) in those with achondroplasia has been reported occasionally in the literature previously. Other disorders arising from constitutive activation of FGFR3 also manifest AN at various frequencies. We assessed the prevalence of AN in a sequential series of 477 individuals with achondroplasia. Using a REDCap database, we collected and analyzed what other features or medical issues may co-occur with AN in those with achondroplasia. AN arises in approximately 10% of individuals with achondroplasia. It usually first appears in preadolescence or adolescence, is more likely in the non-White population and in those who are obese. It is not severe and generally will need no treatment. It is not associated with any evident risk for neither hyperinsulinemic states nor malignancy, and therefore, no special investigations are warranted when it is recognized. Thus, clinicians should not be surprised or concerned upon discovering this finding in those with achondroplasia. In addition, the mechanisms and genetic causes of AN are detailed.

Acanthosis nigricans in the knuckles: An early, accessible, straightforward, and sensitive clinical tool to predict insulin resistance

Any clinical/biochemical marker revealing obesity or diabetes before their appearance is valuable. Insulin resistance (IR) is present in both disorders many years before occurrence. Accordingly, we determined whether acanthosis nigricans (AN) in the knuckles is associated to higher insulin and homeostasis model assessment for estimated insulin resistance (HOMA-IR) index values, and assessed the influence of body-mass index (BMI) and the diagnostic performance of AN in the knuckles to detect IR. In this cross-sectional controlled study, we included men or women, 18 to 23 years old, with or without AN in the knuckles. In 149 cases with AN in the knuckles and 145 controls, fasting insulin was higher in cases (13.45 µU/mL ± 7.8 vs. 8.59 µU/mL ± 3.63, P < .001, respectively). Mean HOMA-IR index was also higher (2.86 ± 1.68 vs. 1.78 ± 0.77, P < .001). A significant increase in fasting insulin and HOMA-IR values between and within BMI groups from normal through obese category was identified in controls and cases. By multivariate regression analysis, cases with normal BMI were significantly associated to a HOMA-IR ≥2.5 (OR = 3.09, CI95% = 1.75-5.48, P = .001). A model of AN in the knuckles, normal BMI, and increased waist circumference allowed identifying 2 out of 3 cases with HOMA-IR index ≥2.5. AN in the knuckles could be addressed with two aims: as an easy, accessible, and costless diagnostic tool suggesting hyperinsulinemia secondary to IR, and, an early marker of IR even in the absence of overweight or obesity.

Cutaneous Complications in Recipients of Lung Transplants: A Pictorial Review

Lung transplant is now an established modality for a broad spectrum of end-stage pulmonary diseases. According to the International Society for Heart and Lung Transplantation Registry, more than 50,000 lung transplants have been performed worldwide, with nearly 11,000 recipients of lung transplants alive in the United States. With the increasing use of lung transplant, pulmonologists must be cognizant of the common as well as the unique posttransplant dermatologic complications. Immunosuppression, infections, and a variety of medications and environmental exposures can contribute to these complications. This review aims to provide representative pictures and describe the pathogenesis, epidemiologic characteristics, and clinical manifestations of dermatologic complications encountered among recipients of lung transplants.

Melatonin Treatment Improves Insulin Resistance and Pigmentation in Obese Patients with Acanthosis Nigricans

OBJECTIVE

This study aimed to determine the effects of melatonin on insulin resistance in obese patients with acanthosis nigricans (AN).

METHODS

A total of 17 obese patients with acanthosis nigricans were recruited in a 12-week pilot open trial. Insulin sensitivity, glucose metabolism, inflammatory factors, and other biochemical parameters before and after the administration of melatonin were measured.

RESULTS

After 12 weeks of treatment with melatonin (3 mg/day), homeostasis model assessment insulin resistance index (HOMA-IR) (8.99 ± 5.10 versus 7.77 ± 5.21, p < 0.05) and fasting insulin (37.09 5 ± 20.26 μU/ml versus 32.10 ± 20.29 μU/ml, p < 0.05) were significantly decreased. Matsuda index (2.82 ± 1.54 versus 3.74 ± 2.02, p < 0.05) was significantly increased. There were also statistically significant declines in the AN scores of the neck and axilla, body weight, body mass index, body fat, visceral index, neck circumference, waist circumference, and inflammatory markers.

CONCLUSIONS

It was concluded that melatonin could improve cutaneous symptoms in obese patients with acanthosis nigricans by improving insulin sensitivity and inflammatory status. This trial is registered with ClinicalTrials.gov NCT02604095.

Prevalence of Acanthosis nigricans and Related Factors in Iranian Obese Children

INTRODUCTION

Recognition of Acanthosis nigricans (AN) provides important opportunities for screening of obesity syndrome, dyslipidemia, hypertension and insulin resistance with diabetes mellitus 2. Considering the high prevalence of obesity among Iranian children, we designed this study to estimate the prevalence of AN and related laboratory factors in Iranian obese children.

MATERIALS AND METHODS

Seventy-one obese children were enrolled in this study. Diagnosis of AN was done by clinical examination. Body mass index (BMI), fasting blood sugar, total cholesterol, triglycerides (TG), alanine aminotransferase, aspartate aminotransferase (AST), alkaline phosphatase, high- and low-density lipoprotein cholesterol, insulin, thyroid-stimulating hormone, free thyroxin (fT4), calcium, phosphorus and 25-hydroxyvitamin D were measured with routine techniques. Collected data were compared between cases with AN and without AN. Independent t-test was used for comparison of variables.

RESULTS

Twenty-five of children were female (35.2%). Forty-eight children (67.6%) had AN. In 20 cases (28.2%), homeostasis model assessment-insulin resistance (HOMA-IR) was <2.5 and in 51 (71.8%), HOMA-IR was more than 2.5. Mean BMI, insulin, HOMA-IR, TG and AST levels were significantly higher in cases with AN.

CONCLUSION

Obese children with AN are at risk of developing diabetes. Hence early identification of this feature and precise evaluation of children is recommended.

Facial Hyperpigmentation in Skin of Color: Special Considerations and Treatment

Differences in cutaneous diseases in people of color call for nuanced evaluation and management. One of the most common dermatological complaints from patients with skin of color is dyspigmentation, particularly hyperpigmentation. The challenge for clinicians is to establish correct diagnoses along with consistently successful treatments to meet the needs of the increasingly diverse population served. This review focuses on facial hyperpigmentation and outlines the most common skin disorders and treatment options.

Skin: A mirror of internal malignancy

Skin manifestations are a reflection of many of the internal diseases. Sometimes, skin disease may be the only manifestation of the internal disease. Internal malignancies may give rise to a number of cutaneous manifestations through their immunological, metabolic, and metastatic consequences. Curth proposed criteria to establish a causal relationship between a dermatosis and a malignant internal disease. Malignancy can present with a plethora of cutaneous manifestations. Here, we describe in brief about various skin manifestations of internal malignancies.

Acanthosis nigricans: A screening test for insulin resistance - An important risk factor for diabetes mellitus type-2

Background:

Acanthosis nigricans (AN) is one of the signs suggestive of high insulin resistance (IR). IR is one of the mechanisms involved in pathogenesis of diabetes mellitus type-2 (DM Type-2). Thus, early detection of IR in children may allow us time to intervene well before the development of DM Type-2. In this study, 62% of children having AN had high IR. In children having both, AN and high body mass index (BMI), the incidence of IR was about 80%. This suggests that these easily detectable parameters alone can be useful in screening children at high risk of developing DM Type-2 in future. These simple criteria thus hold promise for use in high throughput screening programs for diabetes.

Context:

A pilot study conducted by the authors showed that children with AN have a high incidence of IR. The detection of IR in children may allow us time to intervene well before the development of DM Type-2. Detection of DM Type-2 by hyperglycemia may be too late to prevent the onset of microvascular changes.

Aims:

This study aims to determine whether easily observable presence of AN can be used to screen for increased IR in children, and thereby to detect this important risk factor for DM Type-2.

Settings and Design:

Cross-sectional, observational study. Two schools, one with children belonging to average economic background and the other, a residential school with children of affluent parents. Selection of children was done randomly.

Subjects and Methods:

The study was conducted among 507 children in the age group of 10–18 years. Physical examination for the detection of AN, height and weight measurements, waist circumference, fasting plasma glucose, fasting plasma insulin, and lipid profile was done. Homeostatic model assessment of insulin resistance was calculated.

Statistical Analysis Used:

Data analysis was performed using descriptive statistics and inferential statistical methods. The association between categorical variables was done by Chi-square test.

Results:

The presence of AN positively correlated with high IR, and when combined with increased BMI, the incidence rate of IR is 80%.

Conclusions:

AN can be used as a screening method to identify children at risk of DM Type-2-since those who have high IR have a high possibility of having DM Type-2 in future. Hence, early screening and simple, but effective interventional strategies can be instituted at this age, which may prevent or delay diabetes in the long run.

Acanthosis nigricans in obese adolescents: prevalence, impact, and management challenges

Obesity in adolescence is a public health priority because it usually tracks into adulthood, resulting in enormous medical and social costs. This underscores the importance of early identification and intervention. Acanthosis nigricans (AN) was once considered a rare paraneoplastic dermatosis, but is now frequently observed in obese adolescents. Current understanding suggests that it is associated with insulin resistance and has a unique role in secondary prevention. The purpose of this narrative review is to provide a comprehensive overview of AN in obese adolescents, covering its history, current knowledge on the condition, its clinical significance, management challenges, and the direction of future research.

Acral manifestations of paraneoplastic and collagen vascular diseases

The skin often signals a number of systemic disease, making skin findings of paramount significance. Paraneoplastic diseases and collagen vascular diseases are vitally important illnesses. Paraneoplastic diseases and collagen vascular diseases may also occur with many different acral skin findings. Paraneoplastic skin diseases, associated with some cancers, are by definition nonmalignant skin disorders. These diseases can occur before, simultaneously, or after the diagnosis of cancer. Acral paraneoplastic diseases include acanthosis nigricans maligna, acquired pachydermatoglyphia, acrokeratosis paraneoplastica, palmoplantar keratoderma, and paraneoplastic nail disorders. Collagen vascular diseases include the acral skin findings of lupus erythematosus, scleroderma, dermatomyositis, and rheumatoid arthritis. Any acral skin finding may be encountered as the first finding of an undiagnosed malignancy or collagen vascular diseases. The role of the dermatologist is significant for often being the first physician to suspect a malignancy or collagen vascular disease.