Type 2 Diabetes Mellitus in Patients With Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is a multisystemic disorder usually seen in females who are in their reproductive age (15-49 years of age). PCOS exhibits insulin resistance and hyperinsulinemia, which make it a pre-diabetic state. The syndrome has many overt changes, like dyslipidemia and hypertension, which increase the risk of cardiovascular diseases. There is also an increased risk of development of hepatic steatosis. Resistance to insulin, increased amount of insulin, and dysfunction of beta-cells are frequent in PCOS, although they are not the only cause for diagnosis. Type 2 diabetes and glucose resistance may result from total or compared insulin insufficiency, which can happen if the beta cells' compensatory response slows down. Pregnancy challenges such as miscarriage, gestational diabetes mellitus (DM), hypertensive disorders of pregnancy, more excellent rates of cesarean birth, and abnormalities in fetal development may be more common in women with PCOS. In studies investigating the glucose-insulin system compared to control groups with similar age and weight, glycemic intolerance, which includes both decreased glucose tolerance and type 2 diabetes, was more common in PCOS women. In the short-term therapy of insulin resistance in PCOS, the potential use of insulin-sensitizing medications has recently been studied. Controlled studies have demonstrated that metformin treatment can lower fasting and stimulate plasma insulin levels by encouraging body weight reduction. These findings provide insulin-sensitizing drugs as a unique method in treating ovarian hyperandrogenism and irregular ovulation in PCOS and indicate a new prescription for Metformin. They further assert that long-term metformin treatment may assist in addressing insulin resistance, reducing the risk of type 2 diabetes and cardiovascular-related disease in people who take it.

Acanthosis Nigricans Presenting as Skin Tags: A Case Report

Acanthosis nigricans (AN) is a common chronic disorder that is characterized by velvety-like, hyperpigmented, hyperkeratotic plaques, typically in intertriginous areas. However, atypical presentations have been reported. Here we present a five-year-old boy presented with a one-year history of asymptomatic slowly progressing skin lesions. He is a known case of type 1 diabetes mellites on insulin treatment, otherwise healthy. The review of systems was unremarkable. No similar case was found in the family. Skin examination revealed multiple tiny non-scaly brownish papules on the medial aspects of the upper thighs, bilaterally. Differential diagnosis included skin tags, viral warts, and dermatosis papulose nigra (DPN). Dermoscopic findings revealed a velvety-like appearance on the papules and the normal skin surrounding the papules. A 2-mm punch skin biopsy of the papule revealed papillomatosis of the epidermis, and the granular layer was normal. The dermis was normal. On the basis of the above clinicopathological findings, specifically the velvety texture of the normal skin surrounding the papules, the patient was diagnosed with ANs. The parent was reassured, and we started the patient on daily tretinoin cream.

Acanthosis Nigricans in a Patient with Urothelial Carcinoma Treated with PD-L1 Inhibitor Avelumab, and Secondary Adrenal Insufficiency

Acanthosis nigricans (AN) describes hyperkeratotic and hyperpigmented skin changes and its pathophysiology is linked to the activation of epidermal growth factor receptors. Current literature shows that AN is most commonly diagnosed at the time of the underlying pathology, which may occur under benign or malignant conditions. This case presentation demonstrates the occurrence of AN in a patient following the diagnosis of urothelial carcinoma and ongoing treatment with PD-L1 inhibitor immunotherapy. Subsequent investigations ruled out a secondary malignancy or disease progression; however, metabolic screening identified secondary glucocorticoid induced adrenal insufficiency. AN was persistent in this patient despite adequate treatment, which highlights its co-occurrence in both benign and paraneoplastic conditions.

Assessment of serum chemerin levels in acanthosis nigricans: A case-control study

BACKGROUND

Acanthosis nigricans (AN) is an asymptomatic skin condition linked to several underlying systemic conditions. Chemerin is an adipokine that increases during inflammatory disorders such as metabolic syndrome (MetS).

AIMS

This case-control study investigates the link between AN and the underlying MetS and serum levels of chemerin in individuals with obesity.

PATIENTS/METHODS

Twenty-five adults with AN and obesity (body mass index [BMI] > 30 kg/m² ), 25 adults with obesity but no AN, and 25 healthy controls (BMI < 30 kg/m² ) had their lipid profiles and serum chemerin concentrations examined.

RESULTS

The neck (80.0%) and axilla (68.0%) were the most common sites of AN. In participants with obesity, either alone or with AN, serum chemerin concentrations were significantly higher than in the control group (p < 0.001). Participants with obesity and AN had significantly higher levels of cholesterol, triglycerides (TG), low-density lipoprotein cholesterol (LDL-c), and serum chemerin levels (p < 0.001), and significantly lower high-density lipoprotein cholesterol (HDL-c) levels (p < 0.001) when compared to participants with obesity alone. All participants with obesity and AN (100%) and 88% of those with obesity alone had MetS. Logistic regression revealed that systolic blood pressure >130 mmHg, diastolic blood pressure >85 mmHg, waist circumference >90 cm, TG >150 mg/dl, HDL-c <45 mg/dl, fasting blood glucose >100 mg/dl, and serum chemerin >300 ng/ml were significant (p < 0.05) risk factors for AN.

CONCLUSIONS

Acanthosis nigricans is a non-invasive and reliable sign of the underlying MetS and increased serum chemerin levels among individuals with obesity.

Urinary C-peptide and urinary C-peptide creatinine ratio as markers for insulin resistance in obese children and adolescents

BACKGROUND

Obesity is associated with insulin resistance (IR). Identifying high-risk obese children affected with IR is crucial to apply preventive management. We aimed to assess the diagnostic value of urinary C-peptide (UCP) and urinary C-peptide creatinine ratio (UCPCR) to diagnose IR in obese children.

METHODS

This prospective cross-sectional study was performed on 60 children with obesity as the study group. Sixty healthy children of matched age and sex with normal body mass index (BMI) served as the control group. Hemostasis model for the assessment of IR (HOMA-IR), glycated hemoglobin (HbA1c), fasting blood glucose and insulin, UCP, and UCPCR were assessed in all included children.

RESULTS

UCP and UCPCR were significantly higher in children with obesity (2.075 ± 0.783) ng/ml, (0.200 ± 0.021) nmol/mmol compared to the control group (1.012 ± 0.465) ng/ml, (0.148 ± 0.016) nmol/mmol, respectively. Both UCP and UCPCR were positively correlated with each other and with HOMA-IR, HbA1c, acanthosis nigricans, waist circumference, and BMI. At cutoff ≥2.45, the sensitivity of UCP to diagnose IR in obese children was 71.4%. At cutoff ≥0.20, the sensitivity of UCPCR to diagnose IR in obese children was 87.6%.

CONCLUSIONS

UCP and UCPCR are promising surrogate markers of IR in children and adolescents with obesity. However, UCPCR is a better marker than UCP.

IMPACT

Obesity is associated with IR. Identifying high-risk obese children affected with IR is crucial to apply preventive management. We aimed to assess the diagnostic value of UCP and UCPCR to detect IR in obese children. To the best of our knowledge, we are the first to use UCP and UCPCR to assess IR in obese children. We found that UCP and UCPCR are practical, easy, dependable noninvasive markers to assess IR in children with obesity and could potentially be useful in epidemiological studies and clinical practice.

Acanthosis Nigricans Is a Strong Predictor of Low Blood Calcidiol Levels in Children and Adolescents

Background: Clinical consensus differs as to when blood vitamin D (VD) levels should be measured in children. Obesity and metabolic syndrome are risk factors for low VD levels and are also associated with acanthosis nigricans (AN). Objectives: To test whether the clinical diagnosis of AN is a strong predictor for vitamin D deficiency (VDD) in children. Methods: Within the study period (2015-2020), we identified 677 consecutive individuals (age <18 years) with available calcidiol measurements and compared those with (n = 273) and without (n = 404) AN. Bivariate associations and the occurrence of AN were tested using the chi-squared test. Multivariate logistic regression was performed to control for confounding variables, and adjusted odds ratios with 95% confidence intervals (CI) were reported. Multiple regression analysis was performed, and unstandardized beta coefficients, standard errors, and standardized beta coefficients were reported. Results: Individuals with AN had 3.6 times higher odds of VDD than those without (95% CI: 1.38-9.51, P = 0.009). Males had 0.41 times lower odds of having AN than females (95% CI: 0.21-0.79, P = 0.008). Individuals with vitamin D sufficiency (VDS) were much less likely to be diagnosed with metabolic syndrome compared with those who were vitamin D deficient (P = 0.011), even after adjusting for body mass index z-scores. Conclusion: Children and adolescents with AN are at a higher risk of VDD and should likely be tested for low calcidiol levels.

Physical Examination for Endocrine Diseases: Does It Still Play a Role?

A physical examination represents a fundamental step in diagnosing diseases. Due to the role that hormones play in the regulation of numerous biological processes in various organs and systems, endocrine diseases cause a variety of clinical manifestations that can be easily identified with a careful physical examination and can guide the clinician to specific diagnoses. Furthermore, the presence of specific clinical signs in various endocrine-metabolic diseases can predict the risk of developing comorbidities and serious adverse events. In this article, we present some of the main clinical signs of endocrine-metabolic diseases and the risk of comorbidities, summarizing the pathogenetic mechanisms that lead to their formation. The aim is to highlight how the identification of these specific signs can reduce the number of dynamic tests and the costs necessary to reach the diagnosis and allow the early identification of any complications associated with these diseases, improving the clinical management of affected patients.

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.

Resistance to the Insulin and Elevated Level of Androgen: A Major Cause of Polycystic Ovary Syndrome

PCOS has a wide range of negative impacts on women's health and is one of the most frequent reproductive systemic endocrine disorders. PCOS has complex characteristics and symptom heterogeneity due to the several pathways that are involved in the infection and the absence of a comm14on cause. A recent study has shown that the main etiology and endocrine aspects of PCOS are the increased level of androgen, which is also known as "hyperandrogenemia (HA)" and secondly the "insulin resistance (IR)". The major underlying cause of the polycystic ovary is these two IR and HA, by initiating the disease and its severity or duration. As a consequence, study on Pathogenesis is crucial to understand the effect of "HA" and "IR" on the pathophysiology of numerous symptoms linked to PCOS. A deep understanding of the pattern of the growth in PCOS for HA and IR can help ameliorate the condition, along with adjustments in nutrition and life, as well as the discovery of new medicinal products. However, further research is required to clarify the mutual role of IR and HA on PCOS development.

Skin disease related to metabolic syndrome in women

Sex hormones are involved in pathways of metabolic syndrome (MetS), an observation supported by animal studies. The relationships of sex hormones with components of MetS, such as insulin resistance and dyslipidemia, have been studied in pre- and postmenopausal women. High testosterone, low sex hormone-binding globulin, and low estrogen levels increase the risks of MetS and type 2 diabetes in women. Cutaneous diseases that are sex hormone mediated, such as polycystic ovary syndrome, acanthosis nigricans, acne vulgaris, and pattern alopecia, have been associated with insulin resistance and increased risk for MetS. Furthermore, inflammatory skin conditions, such as hidradenitis suppurativa and psoriasis, increase the risk for MetS. Patients with such skin conditions should be followed for metabolic complications, and early lifestyle interventions toward these populations may be warranted.

Comparison of the efficacy and safety of 0.1% adapalene gel and 0.025% tretinoin cream in the treatment of childhood acanthosis nigricans

BACKGROUND

There have been few published randomized controlled trials for the treatment of childhood acanthosis nigricans (AN) to date.

OBJECTIVE

To assess the efficacy of topical 0.1% adapalene gel compared to 0.025% tretinoin cream in the treatment of childhood AN.

METHODS

An 8-week, randomized, split-neck, comparative study between topical 0.1% adapalene gel and 0.025% tretinoin cream for the treatment of neck hyperpigmentation associated with AN was performed. M index measured by a narrowband reflectance spectrophotometer and both investigator's global evaluation (IGE) and parent's global evaluation (PGE) scales were used to evaluate efficacy.

RESULTS

There was no statistically significant difference between 0.1% adapalene gel and 0.025% tretinoin cream in the treatment of AN-associated hyperpigmentation (P = 0.56). Mean differences in M indices between week 0 and week 8 of 0.1% adapalene and 0.025% tretinoin treatment were 24.2 ± 7.9% and 23.8 ± 8.3% improvement, respectively. Regarding treatment efficacy, 90.0% and 85.0% of participants had more than 75% improvement in IGE in 0.1% adapalene and 0.025% tretinoin treatment sides, respectively. In addition, 75.0% and 65.0% of participants had more than 75.0% improvement in PGE in 0.1% adapalene and 0.025% tretinoin treatment sides, respectively.

LIMITATIONS

Lack of histopathological evaluations.

CONCLUSIONS

We found no significant difference between topical 0.1% adapalene gel and 0.025% tretinoin in the treatment of AN.

De novo mutation in ELOVL1 causes ichthyosis, acanthosis nigricans, hypomyelination, spastic paraplegia, high frequency deafness and optic atrophy

BACKGROUND

Very long-chain fatty acids (VLCFAs) are essential for functioning of biological membranes. ELOVL fatty acid elongase 1 catalyses elongation of saturated and monounsaturated C22-C26-VLCFAs. We studied two patients with a dominant ELOVL1 mutation. Independently, Kutkowska-Kaźmierczak et al. had investigated the same patients and found the same mutation. We extended our study towards additional biochemical, functional, and therapeutic aspects.

METHODS

We did mutation screening by whole exome sequencing. RNA-sequencing was performed in patient and control fibroblasts. Ceramide and sphingomyelin levels were measured by LC-MS/MS. ELOVL1 activity was determined by a stable isotope-labelled [¹³C]malonyl-CoA elongation assay. ELOVL1 expression patterns were investigated by immunofluorescence, in situ hybridisation and RT-qPCR. As treatment option, we investigated VLCFA loading of fibroblasts.

RESULTS

Both patients carried an identical heterozygous de novo ELOVL1 mutation (c.494C>T, NM_001256399; p.S165F) not deriving from a founder allele. Patients suffered from epidermal hyperproliferation and increased keratinisation (ichthyosis). Hypomyelination of the central white matter explained spastic paraplegia and central nystagmus, while optic atrophy was causative for reduction of peripheral vision and visual acuity. The mutation abrogated ELOVL1 enzymatic activity and reduced ≥C24 ceramides and sphingomyelins in patient cells. Fibroblast loading with C22:0-VLCFAs increased C24:0-ceramides and sphingomyelins. We found competitive inhibition for ceramide and sphingomyelin synthesis between saturated and monounsaturated VLCFAs. Transcriptome analysis revealed upregulation of modules involved in epidermal development and keratinisation, and downregulation of genes for neurodevelopment, myelination, and synaptogenesis. Many regulated genes carried consensus proliferator-activated receptor (PPAR)α and PPARγ binding motifs in their 5'-regions.

CONCLUSION

A dominant ELOVL1 mutation causes a neuro-ichthyotic disorder possibly amenable to treatment with PPAR-modulating drugs.

Multiple Oral Mucosal Hamartomas in a 34-Year Old Female

A case of Cowden syndrome (CS) is described in a 34-year-old African American female who reported a history of breast and thyroid malignancies. Clinical examination demonstrated multiple soft, white-pink papules across multiple mucosal surfaces of the oral cavity. Microscopy of the lesions revealed hyperkeratotic surface squamous epithelium with papillomatosis and acanthosis along with elongated rete processes. A genomic polymerase chain reaction direct sequencing using the patient's blood was positive for mutations of the PTEN gene typical of CS.

Skin Manifestations of Insulin Resistance: From a Biochemical Stance to a Clinical Diagnosis and Management

Worldwide, more than 1.9 billion adults are overweight, and around 600 million people suffer from obesity. Similarly, ~382 million individuals live with diabetes, and 40–50% of the global population is labeled at “high risk” (i.e., prediabetes). The impact of these two chronic conditions relies not only on the burden of illnesses per se (i.e., associated increased morbidity and mortality), but also on their increased cost, burden of treatment, and decreased health-related quality of life. For this review a comprehensive search in several databases including PubMed (MEDLINE), Ovid EMBASE, Web of Science, and Scopus was conducted. In both diabetes and obesity, genetic, epigenetic, and environmental factors overlap and are inclusive rather than exclusive. De facto, 70–80% of the patients with obesity and virtually every patient with type 2 diabetes have insulin resistance. Insulin resistance is a well-known pathophysiologic factor in the development of type 2 diabetes, characteristically appearing years before its diagnosis. The gold standard for insulin resistance diagnosis (the euglycemic insulin clamp) is a complex, invasive, costly, and hence unfeasible test to implement in clinical practice. Likewise, laboratory measures and derived indexes [e.g., homeostasis model assessment of insulin resistance (HOMA-IR-)] are indirect, imprecise, and not highly accurate and reproducible tests. However, skin manifestations of insulin resistance (e.g., acrochordons, acanthosis nigricans, androgenetic alopecia, acne, hirsutism) offer a reliable, straightforward, and real-time way to detect insulin resistance. The objective of this review is to aid clinicians in recognizing skin manifestations of insulin resistance. Diagnosing these skin manifestations accurately may cascade positively in the patient’s health by triggering an adequate metabolic evaluation, a timely treatment or referral with the ultimate objective of decreasing diabetes and obesity burden, and improving the health and the quality of care for these patients.

Physical Examination Findings Among Children and Adolescents With Obesity: An Evidence-Based Review

Overweight and obesity affects 1 in 3 US children and adolescents. Clinical recommendations have largely focused on screening guidelines and counseling strategies. However, the physical examination of the child or adolescent with obesity can provide the clinician with additional information to guide management decisions. This expert-based review focuses on physical examination findings specific to children and adolescents with obesity. For each physical examination element, the authors define the finding and its prevalence among pediatric patients with obesity, discuss the importance and relevance of the finding, describe known techniques to assess severity, and review evidence regarding the need for additional evaluation. The recommendations presented represent a comprehensive review of current evidence as well as expert opinion. The goal of this review is to highlight the importance of conducting a targeted physical examination during pediatric weight management visits.

Differentiating confluent and reticulated papillomatosis from acanthosis nigricans

BACKGROUND

Confluent and reticulated papillomatosis (CRP) is an uncommon dermatosis with a reticular pattern. As differentiation between CRP and benign acanthosis nigricans (AN) can be challenging because of their similar clinicopathological features, we aimed to distinguish the two diseases.

METHODS

We retrospectively reviewed the clinical characteristics of 60 CRP and 30 AN patients. Histological examinations were conducted on 33 CRP and 30 AN lesions.

RESULTS

While CRP was concentrated on the trunk, AN mostly appeared in the axilla. In the AN group, the number of obese patients was higher, and acanthosis and papillomatosis were more evident. In both group, increases in Ki-67 and keratin 16 expression were similar. Bacterial infection was detected at a higher rate in CRP lesions than in AN lesions.AN lesions had greater pigmentation because of a high number of melanocytes than CRP lesions.

CONCLUSIONS

The location of skin lesions and body mass index are the main clinical factors that enable differentiation between CRP and AN. The epidermal histological changes in CRP are milder than those in AN. AN lesions also showed a greater degree of pigmentation and melanocytic proliferation.

Acanthosis nigricans: A fold (intertriginous) dermatosis

Acanthosis nigricans (AN) is a mucocutaneous disorder that is characterized by focal or diffuse hyperkeratotic, surfaces, which are symmetrically distributed hyperpigmented lesions of the skin. It rarely affects mucosal surfaces like oral cavities. Although it is commonly seen in adolescents, AN is also increasingly seen in children who are obese. Recent studies have found that AN can be a cutaneous indicator of insulin resistance and malignancy. Acanthosis nigricans has been associated with type 2 diabetes mellitus, obesity, endocrinopathies, drugs, and malignancies.

Malignant acanthosis nigricans associated with prostate cancer: a case report

Background

Acanthosis nigricans is characterized by hyperpigmentation and hyperkeratosis of the skin or mucous membranes. Its malignant form is associated with internal neoplasms, especially gastric adenocarcinoma (55–61%). Coexistence with prostate cancer is uncommon. In the paraneoplastic type of this dermatosis, the skin and mucous lesions are characteristically of more sudden onset and more severe than those in the benign form. The efficacy of various treatment strategies remains disappointing.

Case presentation

We here report a case of 66-year-old Caucasian patient with metastatic prostate cancer and a mild form of acanthosis nigricans that preceded the diagnosis of malignancy and resolved with chemotherapy in parallel with the prostate cancer. The dermatosis recurred when the prostate cancer progressed.

Conclusion

Concurrent acanthosis nigricans and prostate cancer is rare, and few such cases have been reported. Anti-tumor therapy occasionally results in regression of this dermatosis. Underlying malignant disease should be suspected in individuals with elderly-onset of acanthosis nigricans.

Spectrum of cutaneous manifestations of type 1 diabetes mellitus in 500 South Asian patients

BACKGROUND

Data on cutaneous manifestations of type 1 diabetes mellitus (DM) is scarce.

OBJECTIVES

To study the spectrum of dermatoses in patients with type 1 DM and the effects of disease duration and long-term glucose control on these cutaneous manifestations.

SUBJECTS AND METHODS

After prior consent, clinical examination and relevant investigations were done in 500 subjects with type 1 DM enrolled between July 2011 and June 2012. Statistical tests were performed using SPSS 16. The presence of various dermatoses was correlated with the duration of diabetes.

RESULTS

Of five hundred subjects, 339 (67·8%) had one or more dermatoses. The mean age of the patients was 16·9 ± 6·9 years (range 1-25 years) and mean total duration of diabetes was 4·43 ± 4·4 years. Cutaneous adverse effects related to insulin injections (CAII), comprising lipohypertrophy (41%), post-inflammatory hyperpigmentation (3%), lipoatrophy (0·6%) and acanthosis nigricans (0·4%), were the most common findings, followed by limited joint mobility (LJM) (16·8%), xerosis (15·8%) and scleroderma-like skin changes (10%). Patients having long-duration DM (> 4·4 years) were significantly more likely to have lipohypertrophy (P = 0·000), LJM (P = 0·000), scleroderma-like skin changes (P = 0·000), diabetic dermopathy (P = 0·000), acanthosis nigricans (P = 0·005) and skin tags (P = 0·002). Lipohypertrophy, LJM and scleroderma-like skin changes also showed significant correlation with blood glucose level.

CONCLUSIONS

Our study suggests that cutaneous changes are common in young Asian patients with type 1 DM. Information, education and counselling of patients and care givers, and awareness among physicians is essential for the prevention and early management of these dermatoses.

[Skin disorders in diabetes mellitus]

Diabetes mellitus is one of the most common diseases in the Western industrialized countries with about 300 million affected patients worldwide. The hyperglycemic state of diabetes mellitus leads to changes in practically every cell type and organ of the human body. Skin changes are considered the most common manifestations of diabetes mellitus. As skin changes can manifest before onset of diabetes mellitus they may have a diagnostic relevance. Other changes and diseases of the skin develop during the course of diabetes mellitus and may be associated with complications in internal organs or may occur as an adverse effect of antidiabetic therapy. In particular the presence of the diabetic foot syndrome is associated with significantly increased morbidity and mortality of diabetes patients as well as with markedly elevated direct and indirect costs for the health care system. In this article the most common skin diseases of patients with diabetes mellitus as well as their pathophysiology and current treatment are reviewed.

Nursing care in childcare services: Acantose nigricans as a marker for metabolic risk

OBJECTIVE

to analyze the association between the presence of Acantose nigricans and metabolic changes in overweight adolescents, so as to ascertain the relevance of the identification of this marker in the nursing consultation.

METHOD

a cross-sectional study undertaken between April 2009 and April 2010 with 118 adolescents who were service users of the Center for Child Obesity in Campina Grande in the Brazilian State of Paraíba (PB). The presence of Acantose nigricans, and the subjects' anthropometric measurements, were investigated. The following exams were made: insulin, triglycerides, HDL-Cholesterol, Glucose and the homeostatic model of assessment (HOMA-IR).

RESULTS

there was association between the presence of Acantose nigricans and participants with insulin resistance (p=0.008), metabolic syndrome (p=0.031), elevated triglycerides (p=0.045) and altered HDL (p=0.002).

CONCLUSIONS

the suggestion is supported that the detection/identification of Acantose nigricans may be used in the nursing consultation as a tool for identifying overweight adolescents with greater risk of metabolic changes.

Oral malignant acanthosis nigricans associated with endometrial adenocarcinoma

We report a 59-year-old patient with malignant acanthosis nigricans associated with metastasis of endometrial carcinoma. The patient presented papillomatosis lesions that appeared to be benign on multiple skins of body folds, particularly on lips. The lesions in lips and axilla had histological characteristic appearances of acanthosis nigricans, while the masses in abdomen and pelvis were metastasis endometrial adenocarcinoma. The article highlights the importance of biopsy and histopathological diagnosis in presumed benign lesions and the role of doctors in screening for body internal tumors.

[Acral acanthosis nigricans associated with taking growth hormone]

Acanthosis nigricans is a skin lesion characterized by the presence of a hyperpigmented, velvety cutaneous thickening that usually appears in flexural areas. Less frequently, it can occur in other locations, such as the dorsum of hands and feet. In this case it is called acral acanthosis nigricans. It is a dermatological manifestation of systemic disease. It is often associated with insulin resistance-mediated endocrine diseases. A case is presented on a patient with acanthosis nigricans secondary to the use of growth hormone.

Acanthosis nigricans and insulin resistance in overweight children and adolescents

BACKGROUND

Studies have suggested an association between the presence of acanthosis nigricans (AN) and the development of diabetes.

OBJECTIVE

To investigate the association between AN and insulin resistance (IR) in overweight children and adolescents receiving care at the Center for Childhood Obesity, Campina Grande, PB.

METHODS

This cross-sectional study was conducted between April 2009 and April 2010 including 194 individuals of 2 to 18 years of age receiving care within the Brazilian national health network. The presence of acanthosis nigricans was verified and anthropometric measurements were taken. The following tests were performed: insulin, triglycerides, HDL-cholesterol, glucose and homeostasis model of assessment - insulin resistance (HOMA-IR). Statistical analyses were performed using the SPSS software program, version 17.0.

RESULTS

There was a greater prevalence of females (66%), brown-skinned individuals (63.4%), adolescents (61.3%) and severely obese individuals (66.5%). Acanthosis nigricans was identified in 58.2% and IR in 42.7% of the participants. Acanthosis nigricans was associated with being non-white (p = 0.003), with being an adolescent (p = 0.003) and with IR (p = 0.001). Non-white individuals, adolescents and those with insulin resistance were 5.4, 2.47 and 2.66 times more likely to have acanthosis nigricans, respectively.

CONCLUSION

The results of this study indicate a need to train healthcare professionals to identify acanthosis nigricans, since this condition is associated with IR. Identifying acanthosis nigricans in childhood permits the safe and timely treatment of cardiometabolic disorders through careful monitoring and appropriate treatment.

[Extensive fibromata pendulantia. Hydrosurgery as a therapy option using the Versajet technique]

Fibromata pendulantia often appear as small filiform skin tags with a narrow pedicle in the neck, axilla and groin areas. Hitherto, extensive fibromata pendulantia were resected either surgically (curette, scissors, scalpel) or by laser. The present case study of an adipose patient with disseminated fibromata pendulantia in the axillary region in the setting of pseudoacanthosis nigricans introduces the Versajet hydrosurgery technique as an alternative method. It is able to remove tissue and rinse the wound simultaneously by means of a high-pressure water jet.

Serum levels of pigment epithelium-derived factor (PEDF) are positively associated with acanthosis nigricans in obese adolescents

INTRODUCTION

Circulating pigment epithelium-derived factor, or serine protease inhibitor F1, is upregulated during adipogenesis, contributing to obesity-induced insulin resistance. Furthermore, pigment epithelium-derived factor is abundant in stage I melanosomes and has been reported to increase pigment granules and the appearance of mature melanosomes in retinal pigment epithelium. As acanthosis nigricans is a well-recognized clinical marker of insulin resistance, we hypothesized that increased pigment epithelium-derived factor might be associated with the generation of acanthosis nigricans.

METHODS

Acanthosis nigricans, anthropometric measurements, circulating total PEDF and metabolic profiles were assessed in 28 obese adolescents in a hospital-based obesity clinic.

RESULTS

Subjects with acanthosis nigricans (n = 10) showed greater plasma levels of pigment epithelium-derived factor (PEDF) than those without [geometric mean 23.55 (range 15.2-40.2) vs. 9.01 (range 5.5-18.7) μg/ml; P < 0.001]. Although pigment epithelium-derived factor was positively correlated with the homeostasis model assessment for insulin resistance (HOMA-IR) (r = 0.779, P < 0.001; 95% CI 0.573-0.892), as previously reported, for the same degree of insulin resistance, those with acanthosis nigricans exhibited a 2.1-fold (95%CI 2.0-2.3) higher level of pigment epithelium-derived factor.

CONCLUSIONS

While acanthosis nigricans is undoubtedly associated with insulin resistance, its appearance is not ubiquitous in patients at any given level of HOMA-IR. The higher levels of pigment epithelium-derived factor in those with acanthosis nigricans compared with those without, with similar levels of resistance, suggest that pigment epithelium-derived factor levels are associated with acanthosis nigricans.

p38 Inhibition ameliorates skin and skull abnormalities in Fgfr2 Beare-Stevenson mice

Beare-Stevenson cutis gyrata syndrome (BSS) is a human genetic disorder characterized by skin and skull abnormalities. BSS is caused by mutations in the FGF receptor 2 (FGFR2), but the molecular mechanisms that induce skin and skull abnormalities are unclear. We developed a mouse model of BSS harboring a FGFR2 Y394C mutation and identified p38 MAPK as an important signaling pathway mediating these abnormalities. Fgfr2+/Y394C mice exhibited epidermal hyperplasia and premature closure of cranial sutures (craniosynostosis) due to abnormal cell proliferation and differentiation. We found ligand-independent phosphorylation of FGFR2 and activation of p38 signaling in mutant skin and calvarial tissues. Treating Fgfr2+/Y394C mice with a p38 kinase inhibitor attenuated skin abnormalities by reversing cell proliferation and differentiation to near normal levels. This study reveals the pleiotropic effects of the FGFR2 Y394C mutation evidenced by cutis gyrata, acanthosis nigricans, and craniosynostosis and provides a useful model for investigating the molecular mechanisms of skin and skull development. The demonstration of a pathogenic role for p38 activation may lead to the development of therapeutic strategies for BSS and related conditions, such as acanthosis nigricans or craniosynostosis.

The skin function: a factor of anti-metabolic syndrome

The body's total antioxidant capacity represents a sum of the antioxidant capacity of various tissues/organs. A decrease in the body's antioxidant capacity may induce oxidative stress and subsequent metabolic syndrome, a clustering of risk factors for type 2 diabetes and cardiovascular disease. The skin, the largest organ of the body, is one of the major components of the body's total antioxidant defense system, primarily through its xenobiotic/drug biotransformation system, reactive oxygen species-scavenging system, and sweat glands- and sebaceous glands-mediated excretion system. Notably, unlike other contributors, the skin contribution is variable, depending on lifestyles and ambient temperature or seasonal variations. Emerging evidence suggests that decreased skin's antioxidant and excretory functions (e.g., due to sedentary lifestyles and low ambient temperature) may increase the risk for metabolic syndrome. This review focuses on the relationship between the variability of skin-mediated detoxification and elimination of exogenous and endogenous toxic substances and the development of metabolic syndrome. The potential role of sebum secretion in lipid and cholesterol homeostasis and its impact on metabolic syndrome, and the association between skin disorders (acanthosis nigricans, acne, and burn) and metabolic syndrome are also discussed.

Metabolic insights from extreme human insulin resistance phenotypes

As well as improving diagnostic and clinical outcomes for affected patients, understanding the genetic basis of rare human metabolic disorders has resulted in several fundamental biological insights. In some cases understanding extreme phenotypes has also informed thinking about more prevalent metabolic diseases. Insulin resistance underpins the twin epidemics of obesity and type 2 diabetes as well as accounting for many of the metabolic problems encompassed by the term metabolic syndrome. This review provides a brief update on current understanding of human severe insulin resistance syndromes, before highlighting recent insights provided by studies in these rare syndromes into the molecular pathogenesis of elements of the metabolic syndrome.

Association of acanthosis nigricans and skin tags with insulin resistance

Insulin resistance is a metabolic disorder in which target cells fail to respond to normal levels of circulating insulin. Insulin resistance has been associated with presence of acanthosis nigricans and acrochordons. It is known that early diagnosis and early initial treatment are of paramount importance to prevent a series of future complications. These dermatoses may represent an easily identifiable sign of insulin resistance and non-insulin-dependent diabetes.

Acanthosis nigricans as a clinical marker to detect insulin resistance in Caucasian children from West Virginia

The accuracy of acanthosis nigrcans (AN) as a dermatological clinical marker to predict insulin resistance (IR) has not been well established in children. A cohort of obese Caucasian children was prospectively recruited. Demographic data, body mass index values, and laboratory data were compared for the presence or absence of AN. A total of 76 children participated. In all, 46 (60.5%) children had AN, and 34 (44.7%) children were positive for IR (>3.16); 25 (32.9%) children were positive for both AN and IR. Sensitivity, specificity, positive and negative predictive values, and accuracy level for AN to detect IR in the obese children who participated in this study were 73.5%, 50%, 54.3%, 70%, and 49%, respectively. The correlation between insulin and fasting glucose levels in AN-negative or AN-positive patients was low (R (2) = 13% to 17%). Acanthosis nigricans was only a surrogate marker for IR. It is concluded that IR should be examined in every obese West Virginian child irrespective of his or her AN status.

Assessment and management of obesity in childhood and adolescence

The increased prevalence of obesity in childhood and adolescence highlights the need for effective treatment approaches. Initial assessments of these patients should include taking a careful history (investigating comorbidities, family history and potentially modifiable behaviors) and physical examination with BMI plotted on a BMI-for-age chart. The degree of investigation is dependent on the patient's age and severity of obesity, the findings on history and physical examination, and associated familial risk factors. There are several broad principles of conventional management: management of comorbidities; family involvement; taking a developmentally appropriate approach; the use of a range of behavior change techniques; long-term dietary change; increased physical activity; and decreased sedentary behaviors. Orlistat can be useful as an adjunct to lifestyle changes in severely obese adolescents and metformin can be used in older children and adolescents with clinical insulin resistance. Bariatric surgery should be considered in those who are severely obese, with recognition of the need for management in centers with multidisciplinary weight management teams and for surgery to be performed in tertiary institutions experienced in bariatric surgery. Finally, given the high prevalence and chronic nature of obesity, coordinated models of care for health-service delivery for the management of pediatric obesity are needed.

Genetic syndromes of severe insulin resistance

Insulin resistance is among the most prevalent endocrine derangements in the world, and it is closely associated with major diseases of global reach including diabetes mellitus, atherosclerosis, nonalcoholic fatty liver disease, and ovulatory dysfunction. It is most commonly found in those with obesity but may also occur in an unusually severe form in rare patients with monogenic defects. Such patients may loosely be grouped into those with primary disorders of insulin signaling and those with defects in adipose tissue development or function (lipodystrophy). The severe insulin resistance of both subgroups puts patients at risk of accelerated complications and poses severe challenges in clinical management. However, the clinical disorders produced by different genetic defects are often biochemically and clinically distinct and are associated with distinct risks of complications. This means that optimal management of affected patients should take into account the specific natural history of each condition. In clinical practice, they are often underdiagnosed, however, with low rates of identification of the underlying genetic defect, a problem compounded by confusing and overlapping nomenclature and classification. We now review recent developments in understanding of genetic forms of severe insulin resistance and/or lipodystrophy and suggest a revised classification based on growing knowledge of the underlying pathophysiology.