The relationship between acrochordons, obesity, and metabolic syndrome in the pediatric population: A retrospective cohort study

BACKGROUND

Acrochordons or skin tags are common benign skin growths. Several studies explored the relationship between obesity and metabolic syndrome in adults but remains unexplored in children.

METHODS

This was a single-center retrospective cohort study of outpatient dermatology patients between 1 January 2000 to 1 January 2021. Children under 18 years old diagnosed with acrochordons using diagnostic codes International Classification of Diseases, 10th Revision (ICD-10) L91.8 and 9th Revision (ICD-9) 701.8 were included. We collected patient demographics, past medical history, laboratory values, vital signs, and physical exam. Body mass index (BMI) was calculated and stratified into categories based on the Center for Disease Control's BMI-for-Age Growth Charts. Metabolic syndrome was diagnosed when three of the five criteria were met. Data were propensity-matched and compared with NHANES (National Health and Nutrition Examination Survey), which offered a generalizable sample to the US population.

RESULTS

Fifty-five patients under 18 years old with a diagnosis of acrochordons were mostly Caucasian (76%) and female (64%). The mean BMI was 27.3, with 49.5% categorized as obese and 20% as overweight. The mean age of diagnosis was 10.1 years. Acrochordon predominantly appeared in the axilla. In our cohort, three patients (5.5%) met the criteria for metabolic syndrome. The prevalence of obesity (42% vs. 21%), type 2 diabetes mellitus (4.8% vs. 0.6%), hyperlipidemia (8.1% vs. 0%), and hypertension (1.6% vs. 0%) was greater in our cohort compared with NHANES.

CONCLUSIONS

Like the adult population, acrochordons may serve as marker for metabolic disease in the pediatric population.

Acculturation and Health Status in the Children's Healthy Living Program in the Pacific Region

Acculturation/enculturation has been found to impact childhood health and obesity status. The objective of this study is to use cross-sectional data to examine the association between proxies of adult/caregiver acculturation/enculturation and child health status (Body Mass Index [BMI], waist circumference [WC], and acanthosis nigricans [AN]) in the U.S.-Affiliated Pacific Islands (USAPI), Alaska, and Hawai'i. Study participants were from the Children's Healthy Living (CHL) Program, an environmental intervention trial and obesity prevalence survey. Anthropometric data from 2-8 year olds and parent/caregiver questionnaires were used in this analysis. The results of this study (n = 4121) saw that those parents/caregivers who identified as traditional had children who were protected against overweight/obesity (OWOB) status and WC > 75th percentile (compared to the integrated culture identity) when adjusted for significant variables from the descriptive analysis. AN did not have a significant association with cultural classification. Future interventions in the USAPI, Alaska, and Hawai'i may want to focus efforts on parents/caregivers who associated with an integrated cultural group as an opportunity to improve health and reduce child OWOB prevalence.

Comparison of efficacy and safety of tretinoin 0.05% and glycolic acid peeling 70% in axillary and neck lesions of acanthosis nigricans: A single-blinded, randomized trial

BACKGROUND

Acanthosis nigricans is a non-inflammatory skin pigmentary disorder characterized by a dark, velvety appearance, primarily observed in the neck and axillary areas. It is commonly associated with obesity, diabetes, and insulin resistance. Although the primary treatment is correcting the underlying disorders, many aesthetic modalities have been established to improve appearance owing to cosmetic concerns.

AIMS

We aimed to compare and investigate the effectiveness and side effects of tretinoin 0.05% and glycolic acid 70% in treating acanthosis nigricans lesions of the axillary and neck area.

METHODS

This single-blinded, randomized trial recruited patients with neck or axillary involvement. Each patient was randomized to use cream tretinoin 0.05% every other night on one side, while the other side was treated with glycolic acid 70%, which was applied every 2 weeks at the clinic for four consecutive sessions. The study duration was 8 weeks, and patients were evaluated every 2 weeks based on their response to treatment, satisfaction, and side effects.

RESULTS

Thirty patients, including 14 with neck lesions and 16 with axillary lesions, were included. Tretinoin was significantly more effective for axillary lesions in terms of treatment response and patient satisfaction (p = 0.02 and p = 0.008, respectively). It was also shown that as the severity of the lesions increased, the response to treatment and patient satisfaction decreased, specifically when treating axillary lesions with glycolic acid (p = 0.02 and p = 0.03, respectively).

CONCLUSION

Neither method was significantly effective for neck lesions. However, tretinoin 0.05% was shown to be more efficacious in treating axillary lesions of acanthosis nigricans, despite causing minimal side effects.

Combination of metformin with liraglutide in treating HAIR-AN syndrome in children A case report and literature review

Hyperandrogenism-insulin resistance-acanthosis nigricans (HAIR-AN) syndrome is a special and rare subtype of polycystic ovarian syndrome. It can lead to hyperandrogenism (HA), insulin resistance (IR), and acanthosis nigricans (AN) accompanied by acne, hirutism, irregular menstruation, and other androgen excess symptoms. A case of pediatric HAIR-AN syndrome with severe AN was admitted to the Department of Endocrinology, China-Japan Friendship Hospital. The patient's clinical manifestations, laboratory data, imaging features, and gene sequencing were analyzed, and the patient was diagnosed with pediatric HAIR-AN syndrome. Obesity, IR, hyperglycemia, menstrual disorder, and AN were significantly improved after treating with metformin and liraglutide. HAIR-AN syndrome occurs in various forms. When the patient appears unexplained acanthosis nigricans and menstrual disorders, the disease should be considered possible. Early diagnosis and symptomatic supportive treatment can improve the quality of life.

Cutaneous Manifestations Associated with Diabetes Mellitus-A Retrospective Study

Diabetes mellitus (DM) is one of the world's most important health problems, affecting more than half a billion of the world's population today, with an ever-increasing prevalence. Among the most common manifestations of diabetes are skin manifestations, with 30-70% of patients experiencing skin complications during the course of the disease. Conditions such as acanthosis nigricans, diabetic dermopathy, necrobiosis lipoidica, bacterial infections, fungal infections, skin xerosis, and metabolic prurigo are often associated with diabetes and often precede its diagnosis. We conducted a retrospective study on a group of 103 patients hospitalized between January 2018 and December 2022, in a clinic of a county hospital, using as criteria the diagnosis of diabetes mellitus complicated by cutaneous manifestations frequently associated with diabetes. The aim was to observe which are the most common manifestations and whether they correlate with data in the research literature. In the present study, manifestations such as diabetic foot (20% of patients), bacterial (35%) and fungal infections, and cutaneous xerosis (45%) were predominant. Often, the integumentary involvement may precede the diagnosis of the underlying disease. It is therefore very important to recognize, investigate and treat these manifestations as soon as possible.

A Novel In Vitro Assay Correlates Insulin Receptor Autoantibodies With Fasting Insulin in Type B Insulin Resistance

CONTEXT

Severe insulin resistance (IR) in the presence of insulin receptor autoantibodies (InsR-aAb) is known as type B insulin resistance (TBIR). Considerable progress in therapy has been achieved, but diagnosis and monitoring of InsR-aAb remains a challenge.

OBJECTIVE

This work aimed to establish a robust in vitro method for InsR-Ab quantification.

METHODS

Longitudinal serum samples from patients with TBIR at the National Institutes of Health were collected. A bridge-assay for InsR-aAb detection was established using recombinant human insulin receptor as bait and detector. Monoclonal antibodies served as positive controls for validation.

RESULTS

The novel assay proved sensitive, robust, and passed quality control. The measured InsR-aAb from TBIR patients was associated with disease severity, decreased on treatment, and inhibited insulin signaling in vitro. Titers of InsR-aAb correlated positively to fasting insulin in patients.

CONCLUSION

Quantification of InsR-aAb from serum samples via the novel in vitro assay enables identification of TBIR and monitoring of successful therapy.

Pediatric obesity and skin disease: cutaneous findings and associated quality-of-life impairments in 103 children and adolescents with obesity

Objective

Little is known about specific cutaneous findings in children and adolescents with overweight and obesity. This study assessed the association of skin signs with pivotal auxological and endocrinological parameters and their influence on the quality of life (QoL) of young people with obesity.

Study design

All patients initially recruited for a tertiary hospital's weight control program were offered participation in this interdisciplinary, single-center, cross-sectional study. All participants underwent a detailed dermatological examination, anthropometric measurements and laboratory examinations. QoL was assessed with validated questionnaires.

Results

A total of 103 children and adolescents (age 11.6 ±2.5 years, 41% female, 25% prepubertal, BMI SDS 2.6 ± 0.5, homeostatic model assessment (HOMA) score 3.3 ± 4.2; mean ± s.d.) were recruited in a 12-month study period. Skin affections were linearly associated with increasing BMI and higher age. The most common skin findings were (%) striae distensae (71.0), keratosis pilaris (64.7), acanthosis nigricans (45.0), acne vulgaris (39.2), acrochordons (25.5) and plantar hyperkeratosis (17.6). The HOMA score was associated with acanthosis nigricans (P = 0.047), keratosis pilaris (P = 0.019) and acne vulgaris (P < 0.001). The general mean QoL(QoL) score, as assessed by the WHO-5, was 70 out of 100. A total of 38.9% of participants reported impaired dermatological QoL.

Conclusions

This study shows the high prevalence of skin lesions in children and adolescents with obesity. The association between skin lesions and the HOMA score indicates that skin manifestations are a marker of insulin resistance. To prevent secondary diseases and improve QoL, thorough skin examinations and interdisciplinary cooperation are necessary.

Diet and Acanthosis Nigricans over a Two-Year Period in Children of the Pacific Region

BACKGROUND

The impact that dietary carbohydrates have on children developing type 2 diabetes remains controversial. Furthermore, there are limited pediatric longitudinal studies on changes in body mass index (BMI) and diet related to the development of acanthosis nigricans (AN), a risk factor associated with type 2 diabetes.

METHODS

Two 24 h dietary records were collected for 558 children, 2-8 years of age, at baseline and at a 2-year follow-up. Data on age, sex, BMI, and the presence of AN were also collected at each time point from the Children's Healthy Living Program. Logistic regression was used to determine factors associated with the presence of AN at follow-up. Multinominal regression was used to determine factors associated with changes in AN status. Linear regression was used to measure the associations between changes in dietary intake and in the Burke Score for AN.

RESULTS

AN was present in 28 children at baseline and 34 children at follow-up. Adjusting for the presence of AN at baseline, age, sex, study group, baseline BMI, change in BMI z-score, time between assessments, and baseline intake, an increase from baseline for each teaspoon of sugar and serving of carbohydrate-rich food increased the risk for having AN at follow-up by 9% and 8%, respectively (p ≤ 0.05). An increased intake of added sugar (teaspoons) increased the risk of developing AN by 13% (p ≤ 0.01) and an increase in servings of foods rich in starch increased the risk of developing AN by 12% (p ≤ 0.01) compared to children who never had AN. Increasing the intake of fruit was also associated with decreased Burke Scores using multiple regression. However, the intake of energy and macronutrients were not associated with AN.

CONCLUSIONS

Added sugar and foods rich in starch were independently associated with the occurrence of AN, suggesting the type of carbohydrates consumed is a factor in AN occurrence.

Confluent and Reticulated Papillomatosis Resembling Pityriasis Versicolor and Acanthosis Nigricans: Case Report

Confluent and reticulated papillomatosis (CARP) is a rare disorder mostly seen in young adults. It is characterized by persistent dull-brown, centrally confluent, peripherally reticulate macules and papules, which coalesce to form patches and plaques on the upper trunk and neck. It is commonly confused with pityriasis versicolor and acanthosis nigricans (AN). We report the case of a 15-year-old male with multiple pigmented confluent and reticulated patches and plaques on the neck, trunk, and chin for 3 years, which was successfully treated with oral minocycline, resulting in complete resolution of lesions within 2 weeks. The morphology of CARP resembles that of various other dermatological conditions such as AN and pityriasis versicolor, and, as a result, it is frequently misdiagnosed and mistreated, leading to social embarrassment for the patient. Therefore, it is prudent for dermatologists to carry out comprehensive clinical and histopathological assessments to facilitate prompt diagnosis and management of this condition.

T follicular helper phenotype mycosis fungoides associated with acanthosis nigricans

The association between acanthosis nigricans (AN) and mycosis fungoides (MF) has rarely been described, but it is known that MF may appear as AN-like vegetating and papillomatous plaques in skin folds, or may be associated with paraneoplastic AN. There have also been recent descriptions of a form of "intertriginous MF" that is characterized by skin fold involvement and the expression of T follicular helper (TFH) markers, and that often has an aggressive course. We describe the case of a 48-year-old man affected by MF associated with AN, whose lesions were characterized by a TFH immunophenotype and the expression of the GATA-3 nuclear master regulator that may be related to a TFH-2 subpopulation or possible disease progression.

Ethnicity in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the commonest gynecological endocrinopathy. Little is known about the exact etiopathogenesis and cardiometabolic mortality and morbidity in women with PCOS. PCOS is beyond the cosmetic concerns of an adolescent and fertility concerns of an adult and can cause serious unhealthy consequences in perimenopausal and postmenopausal age. This area needs to be assessed and addressed since the majority of these patients are lost to follow-up after completion of their families. Good evidence suggests that there are significant racial and ethnic differences in prevalence, insulin resistance, metabolic syndrome, hyperandrogenemia and the related cardiometabolic risk in women with PCOS.

Resolution of Hyperandrogenism, Insulin Resistance and Acanthosis Nigricans (HAIR-AN) Syndrome After Sleeve Gastrectomy

Hyperandrogenism, insulin resistance, and acanthosis nigricans (HAIR-AN) is a severe subphenotype of polycystic ovary syndrome (PCOS). A 32-year-old woman with HAIR-AN and class 3 obesity presented to an endocrinology clinic after she failed sequential trials of treatment with metformin, estrogen-progestin OCP, spironolactone, leuprolide, and a levonorgestrel intrauterine device. She complained of hirsutism and acanthosis nigricans severely affecting her quality of life and had secondary amenorrhea. Laboratory evaluation showed extremely elevated testosterone and insulin levels and elevated glycated hemoglobin A1c (HbA1c). She underwent laparoscopic sleeve gastrectomy. One year after the surgery, she lost 32% of her body weight and reported normalization of menses, dramatic improvement in hirsutism, and near-resolution of acanthosis nigricans. Her testosterone, insulin, and HbA1c normalized. This case demonstrates the central role of hyperinsulinemia in HAIR-AN and suggests that aggressive measures to normalize insulin resistance and reduce excess weight can effectively treat the reproductive abnormalities in this syndrome. We suggest that bariatric surgery can be an effective cure for HAIR-AN syndrome and that PCOS, including HAIR-AN, should be considered a comorbidity of obesity during evaluation of bariatric surgery candidates.

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.

Efficacy of Fractional Carbon Dioxide (CO2) Laser versus Q-Switched Neodymium-Doped Yttrium Aluminum Garnet (Nd:YAG) and Potassium-Titanyl-Phosphate (KTP) Lasers in the Treatment of Acanthosis Nigricans

Background

Acanthosis nigricans (AN) is a common chronic skin disorder clinically presents by velvety hyperpigmented lesions mainly at the flexural areas. Fractional photothermolysis has been reported to improve both pigmentary and textural changes by removing thin layers of skin with minimal thermal damage. Other options are the Q-switched (Qs) Nd:YAG (1064 nm) and Qs KTP (532 nm) lasers. Both can induce collagen remodeling by dermal photo-mechanical microdamage.

Aim of the Work

The aim of this study was to assess the clinical efficacy and the safety of fractional CO₂ laser versus Qs Nd:YAG and KTP lasers in the treatment of acanthosis nigricans.

Methods

This randomized-controlled split neck study was conducted on 23 patients suffering from AN. For each patient, one side of the neck was randomly assigned to fractional CO₂ laser and the other side to Qs Nd:YAG and KTP lasers every four weeks for four months followed by 4 monthly follow-up assessment. Acanthosis Nigricans Area and Severity Index (ANASI) score, melanin and erythema indices as well as Patient Satisfaction Scale (PSS) were used to assess improvement on each side separately.

Results

There was no statistically significant difference regarding the clinical improvement between the side treated with Fractional CO₂ laser and the side treated with Qs Nd:YAG and KTP lasers (P value >0.05). In most patients, both sides showed improvement during different sessions of therapy, as regards ANASI scores, melanin indices, patient satisfaction scores, and side effects.

Conclusion

In this study, we concluded that both fractional CO₂ and Q-switched lasers proved to be a safe and effective line of treatment of acanthosis nigricans.

Cardiometabolic risk factors among children who are affected by overweight, obesity and severe obesity

Background

The increasing severity of obesity is expected to lead to more serious health effects. However, there is limited information on the prevalence and clinical characteristics of cardiometabolic risk factors in severely children affected by obesity in Malaysia. This baseline study aimed to investigate the prevalence of these factors and their association with obesity status among young children.

Methods

In this study, a cross-sectional design was employed using the baseline data obtained from the My Body Is Fit and Fabulous at school (MyBFF@school) intervention program involving obese school children. Obesity status was defined using the body mass index (BMI) z-score from the World Health Organization (WHO) growth chart. Cardiometabolic risk factors presented in this study included fasting plasma glucose (FPG), triglycerides (TGs), total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), blood pressure, acanthosis nigricans, insulin resistance (IR), and MetS. MetS was defined using the International Diabetes Federation (IDF) 2007 criteria. Descriptive data were presented accordingly. The association between cardiometabolic risk factors, such as obesity status, and acanthosis nigricans with MetS was measured using multivariate logistic regression, which was adjusted for gender, ethnicity, and strata.

Results

Out of 924 children, 38.4% (n = 355) were overweight, 43.6% (n = 403) were obese, and 18% (n = 166) were severely obese. The overall mean age was 9.9 ± 0.8 years. The prevalence of hypertension, high FPG, hypertriglyceridemia, low HDL-C, and the presence of acanthosis nigricans among severely children affected by obesity was 1.8%, 5.4%, 10.2%, 42.8%, and 83.7%, respectively. The prevalence of children affected by obesity who were at risk of MetS in <10-year-old and MetS >10-year-old was observed to be similar at 4.8%. Severely children affected by obesity had higher odds of high FPG [odds ratio (OR) = 3.27; 95% confdence interval (CI) 1.12, 9.55], hypertriglyceridemia (OR = 3.50; 95%CI 1.61, 7.64), low HDL-C (OR = 2.65; 95%CI 1.77, 3.98), acanthosis nigricans (OR = 13.49; 95%CI 8.26, 22.04), IR (OR = 14.35; 95%CI 8.84, 23.30), and MetS (OR = 14.03; 95%CI 3.97, 49.54) compared to overweight and children affected by obesity. The BMI z-score, waist circumference (WC), and percentage body fat showed a significant correlation with triglycerides, HDL-C, the TG: HDL-C ratio, and the homeostatic model assessment for IR (HOMA-IR) index.

Conclusions

Severely children affected by obesity exhibit a higher prevalence of and are more likely to develop cardiometabolic risk factors compared to overweight and children affected by obesity. This group of children should be monitored closely and screened periodically for obesity-related health problems to institute early and comprehensive intervention.

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.

Association between acanthosis nigricans and overweight with hypertension in children and adolescents from low-income families

OBJECTIVE

This study aimed to describe the prevalence of acanthosis nigricans and high blood pressure in children and adolescents from low-income families, and to verify the association of elevated blood pressure with nutritional status and the presence of acanthosis nigricans.

METHODS

This is a cross-sectional and controlled study with 232 children and adolescents from an institution for low-income families. Pubertal stage, body mass index Z-score, waist-to-height circumference ratio (increased waist-to-height circumference ratio >0.5), the presence of acanthosis nigricans, and blood pressure were assessed.

RESULTS

The prevalence of excess weight and the change in waist-to-height circumference ratio was 37.9%. Acanthosis nigricans and increased blood pressure occurred in 20.3 and 34.8%, respectively. The prevalence of acanthosis nigricans and hypertension was higher in individuals with excess weight (p<0.001; p<0.001) and with an increased waist-to-height circumference ratio (p=0.009; p<0.001). Logistic regression showed a significant and independent association of body mass index Z-score (OR 2.35; 95%CI 1.52-3.65; p<0.001) and the presence of acanthosis nigricans (OR 2.43; 95%CI 1.12-5.23; p=0.023) with elevated blood pressure.

CONCLUSION

Acanthosis nigricans and elevated blood pressure occurred in one-fifth and one-third of the individuals in an institution for children from low-income families. Overweight and the presence of acanthosis nigricans increased the risk of high blood pressure more than twofold.

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.

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.

Cutaneous manifestations of obesity in Turkish children: A comparative study

BACKGROUND

Cutaneous changes in obese adults have been investigated in numerous studies, but this issue has not been adequately investigated in children.

OBJECTIVES

We aimed to determine the prevalence of skin manifestations in children with obesity by comparing them to normal-weight children.

METHODS

A cross-sectional study was conducted between June 2017 and January 2019 in which 82 children with obesity and 86 normal-weight healthy control children were enrolled. Study participants had detailed full-body skin examinations performed by the same dermatologist; mycological and Wood's lamp examinations were performed when necessary. Sociodemographic and anthropometric measurements of the participants were recorded.

RESULTS

Striae distensae were the most common skin manifestation in children with obesity; striae were significantly higher in the obese than in the control group (72% vs. 26.7%, p < .001). The anatomical distribution of the striae distensae in the groups differed significantly. Striae distensae were most commonly observed on the buttocks in the control group, while the thighs were the most common site in the obese group. Acanthosis nigricans (63.4% vs. 3.5%, p < .001), acrochordons (17.1% vs. 1.2%, p < .001), keratosis pilaris (32.9% vs. 17.4%, p = .021), intertrigo (11% vs. 0%, p = .001), folliculitis (31.7% vs. 5.8%, p < .001), seborrheic dermatitis (12.2% vs. 3.5%, p = .035) and facial erythema (7.3% vs. 0%, p = .012) were found to be statistically significantly more common in the obese group compared to the control group.

CONCLUSIONS

Obesity in children is associated with numerous cutaneous manifestations. Further study is needed to identify whether weight loss can reduce skin manifestations in obese children.

Confluent and reticulated papillomatosis in pediatric patients at an urban tertiary care center

Confluent and reticulated papillomatosis (CARP) is a dermatosis that often presents during adolescence. Prior studies have linked CARP to metabolic syndrome and comorbidities associated with insulin resistance, such as acanthosis nigricans and type 2 diabetes. Despite this, few studies have evaluated the clinical relationship between glucose dysmetabolism and CARP. In this report, we describe the characteristics of a large cohort of pediatric patients with CARP to further evaluate the potential relationship between CARP and metabolic syndrome in children.

Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report

SUMMARY

Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting.

LEARNING POINTS

Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.

High Prevalence of Cardiometabolic Comorbidities Among Children and Adolescents With Severe Obesity From a Large Metropolitan Centre (Hangzhou, China)

OBJECTIVE

This study aimed to describe the clinical characteristics of children and adolescents with obesity, and the prevalence of cardiometabolic comorbidities over 10 years in this population from a large metropolitan centre in China.

METHODS

This was a cross-sectional study (2008-2017) of patients aged <18 years with obesity [body mass index (BMI) ≥ 95th percentile for age and sex] enrolled at the Department of Endocrinology, Children's Hospital of Zhejiang University School of Medicine (Hangzhou, Zhejiang Province). Clinical assessments included anthropometry, blood pressure, liver ultrasound, lipid profile, oral glucose tolerance test, and uric acid. For examination of outcomes, our study cohort was stratified by sex and age bands (<10 vs. ≥10 years), with the study period also split into two strata (2008-2012 and 2013-2017).

RESULTS

A total of 2,916 patients (1,954 boys and 962 girls) were assessed at a mean age of 10.5 years. Patients almost invariably presented severe obesity (median BMI SDS = 2.98; Q1 = 2.60, Q3 = 3.39). Obesity-related comorbidities were common among boys and girls, including type 2 diabetes mellitus (2.6% and 3.6%, respectively), abnormal glycaemia (33.6% and 35.5%, respectively), hypertension (33.9% and 32.0%, respectively), dyslipidaemia (35.2% and 39.6%, respectively), hyperuricaemia (16.2% and 8.3%, respectively), acanthosis nigricans (71.9% and 64.0%, respectively), abnormal liver function (66.9% and 47.0%, respectively), and non-alcoholic fatty liver disease (NAFLD) (63.8% and 45.1%, respectively); 38.7% of boys and 44.4% of girls aged ≥10 years had metabolic syndrome. Notably, the incidence of many cardiometabolic comorbidities was in 2013-2017 compared to 2008-2012. For example, rates of hypertension among boys aged <10 years and aged ≥10 years rose from 28.4% and 26.5% to 48.0% and 35.8%, respectively, and in girls from 20.3% and 20.8% to 41.7% and 39.6%, respectively. In 2013-2017, 9.5% of girls in the older group had metabolic syndrome compared to 2.2% in 2008-2013.

CONCLUSIONS

We observed a high incidence of obesity-related cardiometabolic comorbidities among Chinese children and adolescents with severe obesity over 10 years. It was particularly concerning that rates of several comorbidities rose markedly over the study period, highlighting the need to address the obesity epidemic early in life (in China and elsewhere) to prevent the development of obesity-related comorbidities and, subsequently, of overt disease.

Treatment of acanthosis nigricans with sequential salicylic acid-mandelic acid combination peel and maintenance with glycolic acid-urea combination cream: A retrospective pilot study

BACKGROUND

Acanthosis nigricans (AN) is a common dermatosis that presents with hyperpigmented, velvety thick plaques over intertriginous areas. Though a number of treatment modalities including chemical peels have been used, none provide long-term and sustained improvement.

AIM AND OBJECTIVES

Our study evaluated the efficacy and safety of regular sessions of salicylic acid-mandelic acid peeling over axillary AN lesions, which was followed by daily application of a topical combination of glycolic acid, urea, and cetylated fat esters for maintenance of effect for 9 months.

METHODOLOGY

A retrospective pilot study was conducted in Indian patients (Fitzpatrick skin type 4 or 5), aged 18-50 with benign hereditary AN involving the underarms, with or without affection of other typical sites. Data were retrieved of seventeen patients with AN involving the axillae. Patients were started on combination salicylic-mandelic acid peel given every 2 weeks for a total of 6 sessions. Maintenance was done by night application of combination cream of glycolic acid, urea, and cetylated fat esters, which was continued for 9 months after completion of peeling sessions. Lesions were evaluated every 3 months of 9 months for improvement in pigmentation and skin thickening.

RESULTS

All the patients (100%) showed significant improvement in both pigmentation and thickening of lesions. In terms of improvement in skin thickening, very good improvement was seen in 41%, while 29% patients had moderate improvement. In terms of improvement in pigmentation, 35% each had very good and moderate improvement. Post peel erythema (100%) and burning sensation (90%) were the most common encountered adverse effects which lasted for only 1-2 days. Patients were followed up for another 9 months during which no relapses were seen.

CONCLUSION

Combination of keratolytic chemical peels and topical mild keratolytic application ensures better therapeutic outcome in patients of AN with long lasting effect.

[Correlation between total testosterone levels and insulin resistance in patients with acanthosis nigricans and non-acanthosis nigrican]

OBJECTIVE

To investigate the correlation of the total testosterone (TT) level with insulin secretion and resistance in patients with acanthosis nigricans (AN) and non-acanthosis nigricans (NAN).

METHODS

This study was conducted in a total of 639 overweight patients (body mass index ≥24 kg/m²), including 137 female AN patients, 277 female NAN patients, 129 male AN patients, and 146 male NAN patients. Each group was further divided into 4 subgroups according to the quartile of TT level for comparison of insulin secretion and insulin resistance parameters.

RESULTS

Both female and male patients with AN showed obvious hyperinsulinemia with increased area under the curve for insulin (AUC-INS) (P < 0.05), increased homeostatic model assessment of insulin resistance (HOMA-IR) index (P < 0.05) and decreased whole-body insulin sensitivity index (WBISI) (P < 0.01) as compared with those in NAN groups, but these parameters did not show significant variations with the change of TT levels. In female patients with NAN, insulin secretion level increased progressively as the TT level increased; the AUC-INS increased (P < 0.01) and WBISI decreased significantly (P < 0.05) when the TT levels increased to Q4. In male patients with NAN, insulin secretion level increased progressively as the TT levels decreased, and the AUC-INS increased (P < 0.05) and the WBISI decreased significantly (P < 0.05) when the TT levels decreased to Q1.

CONCLUSIONS

The TT level has a significant effect on insulin resistance and insulin secretion, but its effect varies between genders and is more significant in NAN patients than in AN patients.

Skin anomalies in acromegalic patients (Review of the practical aspects)

Acromegaly is a hormonal disorder which occurs as the result of growth hormone (GH) and insulin growth factor 1 (IGF-1) over-secretion; both hormones are related to skin anomalies. The skin acts as a large endocrine organ, hosting GH receptors in every cell while IGF-1 receptors are expressed only in keratinocytes. This review is a literature review of skin anomalies found in acromegaly, either related to the disease itself or associated with related complications such as secondary diabetes mellitus, or involving associated conditions such as genetic syndromes. The following clinical points are mentioned as follows. Excessive skin and enlargement of soft tissue are due to glycosaminoglycan deposits, edema, and hyperhidrosis (mostly facial and acral). Acanthosis nigricans, a body fold dermatosis associated with insulin resistance, involves local or diffuse hyperkeratotic plaques with or without hyperpigmentation, caused by growth factors including GH/IGF-1. Other findings include cherry angiomas (due to the effects of lipid anomalies on small vessels); oily skin features with keratosis, epidermoid cysts, crochordons, pseudo-acanthosis nigricans; a potentially higher prevalence of varicose veins and psoriasis; low level of evidence for basal cell carcinoma, respective hidroadenitis suppurativa has been noted. In addition, complicated uncontrolled secondary diabetes mellitus (DM) may result in necrobiosis lipoidica diabeticorum, diabetic dermopathy, skin bacterial infections, dermatological complications of diabetic neuropathy, and nephropathy. Finally, associated hereditary syndromes may cause collagenomas, fibromas/angiofibromas, lipomas in multiple endocrine neoplasia type 1 (MEN1) syndrome; café-au-lait macules, early onset neurofibromas, juvenile xanthogranuloma (involving non-Langerhans cell histiocytes), and intertriginous freckling in neurofibromatosis type 1. Clinical findings are differentiated from pseudo-acromegaly such as pachydermoperiostosis. Iatrogenic rash, lipodystrophy (lipoatrophy with/without lipohypertrophy) are rarely reported after pegvisomant/somatostatin analogues or after insulin use for DM. Experiments using human cell lines have shown that GH/IGF-1 over-secretion are prone to epithelial-to-mesenchymal transition (EMT) in melanoma. In non-acromegalic subjects, the exact role of GH/IGF-1 in skin tumorigenesis is yet to be determined. Skin in acromegaly speaks for itself, either as the first step of disease identification or as a complication or part of a complex syndromic context.

The efficacy and safety of 20% urea cream and 10% urea cream in the treatment of acanthosis nigricans in adolescents, a randomized comparative double-blind study

BACKGROUND

Acanthosis nigricans is commonly associated with obesity. It is characterized by brown-black skin thickening on the neck and the flexural areas. This study aimed to assess the efficacy of topical 20% urea cream compared to 10% urea cream in the treatment of acanthosis nigricans in adolescents.

MATERIAL AND METHODS

A randomized comparative, double-blind study was conducted on participants aged 12-18 years with acanthosis nigricans of the neck. Treatment efficacy was assessed via narrowband reflectance spectrophotometer, while the overall success rates at weeks 2, 4, and 8 were evaluated by the investigator- and participant-assessed global evaluation scales.

RESULTS

A total of 40 participants with acanthosis nigricans were enrolled and completed the study. Throughout the period of 8 weeks of treatment, 20% urea showed greater improvement of hyperpigmentation compared to 10% urea (p = 0.001), with 22.5 ± 11.9% and 10.7 ± 8.1% improvements, respectively. Findings from the overall global evaluation scales were consistent with the results from the narrowband reflectance spectrophotometer. Treatment with 10% urea and 20% urea was well-tolerated without any local serious adverse reactions.

CONCLUSION

Urea cream improves neck hyperpigmentation associated with acanthosis nigricans in adolescents, in which the 20% concentration shows superior efficacy to the 10% concentration.

Acanthosis Nigricans in Children and Adolescents with Type 1 Diabetes or Obesity: The Potential Interplay Role between Insulin Resistance and Excess Weight

Acanthosis nigricans (AN) is associated with obesity and type 2 diabetes, where insulin resistance (IR) is considered a predisposing factor. IR can also affect patients with type 1 diabetes (T1D). We evaluated the prevalence of AN in patients with T1D compared to subjects with obesity in order to define the interplay between IR and excess weight. We considered 138 pediatric patients who presented with T1D and 162 with obesity. As controls, 100 healthy normal-weight subjects were included. A physical examination with the detection of AN and biochemical assessments was performed. IR was calculated by using the homeostasis model assessment for IR in patients with obesity and the estimated glucose disposal rate in T1D. The AN prevalence was higher in T1D and obese subjects compared with controls in whom AN was not detected (p = 0.02 and p < 0.001, respectively). A greater number of AN cases were observed in subjects with obesity compared with T1D (p < 0.001). Patients with AN were older than subjects without AN (p = 0.005), and they had higher body mass index (BMI) values, waist circumference (WC), fasting triglycerides and blood pressure (all p < 0.001). Thirty-five patients with AN exhibited IR with an association between AN presence and IR in patients with obesity (p < 0.001). In T1D, there was an association between AN and being overweight/obese (p = 0.02), independently of IR. AN is a dermatological condition associated with obesity. In T1D, the presence of AN was significantly associated with overweight status or obesity but not IR. The presence of AN in the absence of IR supports the interplay role between impaired insulin signaling, IR and excess weight in the pathogenic mechanism.

Comparative study between fractional carbon dioxide laser versus retinoic acid chemical peel in the treatment of acanthosis nigricans

BACKGROUND

Acanthosis nigricans (AN) is a common dermatological issue with several therapeutic modalities to treat. Despite retinoid is the first drug of choice in the treatment, the fractional-ablative carbon dioxide (CO₂ ) laser has revealed as a promising procedure for the management of neck-AN, outstanding to its ability for superficial ablation of the skin surface, with trans-epidermal melanin elimination.

OBJECTIVES

To decide whether fractional-ablative CO₂ laser or retinoic acid (5%) peel is the more effective and safe choice for AN treatment.

METHODS

In this study, twenty Egyptian cases with neck-AN were enrolled, where each case was exposed to four sessions with 2 weeks apart of both fractional CO₂  laser on the right half of the neck and retinoic acid peel on the left half of the neck. Cases were assessed by a scoring system: Acanthosis Nigricans Area and Severity Index (ANASI) score, two blinded dermatologists, and dermoscopically before and one month after treatment.

RESULTS

We found a highly statistically significant improvement among both treated groups regarding (ANASI) score and dermatologist's assessments. Bedside, the degree of sulci cutis, cristae cutis, brown-to-dark brown dots, and milia-like cysts, dermoscopic sign improvement was evident in both treated groups. However, fractional CO₂ laser shows the superior result to retinoic acid peel in the treatment.

CONCLUSION

Fractional CO₂ laser and retinoic acid peel are considered effective modalities for neck-AN treatment. However, fractional CO₂ laser was more effective.

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.

Fractional carbon dioxide laser versus trichloroacetic acid peel in the treatment of pseudo-acanthosis nigricans

BACKGROUND

Treatment of acanthosis nigricans (AN) is challenging, and new modalities are being explored continuously to increase the therapeutic efficacy.

AIM

To evaluate the efficacy and safety of fractional CO2 laser compared to trichloroacetic acid (TCA) peel in the treatment of pseudo-acanthosis nigricans (pseudo-AN).

METHODS

The study included 40 patients with pseudo-AN on the neck and axilla allocated into two groups each containing 20 patients. Group (A) was treated with TCA 20% peel applied on the pigmented area while group (B) received fractional CO2 laser. Both treatments were performed till complete clearance or for a maximum of four treatment sessions. Patients with excellent response were further followed up for 6 months after the end of treatment.

RESULTS

Both modalities were effective in the treatment of pseudo-AN; however, the therapeutic response was significantly higher in the fractional CO2 laser group compared to the TCA peel group (p < 0.01). Marked to excellent response (51%-100% clearance of AN lesions) was achieved in 85% of the patients in the fractional laser group versus 10% of the patients in the TCA group. Adverse effects, for example, persistent erythema, post-inflammatory hyperpigmentation, and burning sensation, were also statistically higher in the TCA group compared to the laser group (p = 0.04).

CONCLUSION

Fractional CO2 laser is a promising effective and well-tolerated treatment modality for pseudo-acanthosis nigricans.

Topical rapamycin for acanthosis nigricans in the Fitzpatrick IV/V adolescent population

Dermatologically, FGFR3 mutations can lead to acanthosis nigricans (AN), epidermal nevi, and seborrheic keratosis. A recent case report found that topical rapamycin (sirolimus) can improve FGFR3-induced epidermal nevi with AN features in children, specifically with Fitzpatrick skin type (FST) I/II, and we would like to expand these findings to skin plaques with extensive AN-like features in the FST IV/V adolescent population. An 18-year-old female with FST IV/V and FGFR3-induced hypochondroplasia presented to our clinic with extensive AN-like plaques. Significant improvement with lightening and thinning of the plaques was observed after applying 1% topical rapamycin cream twice daily. Topical rapamycin should be considered as a treatment option for AN, particularly in FST IV/V adolescents with FGFR3-induced AN.

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.

A Molecular Perspective on the Potential Benefits of Metformin for the Treatment of Inflammatory Skin Disorders

Due to its anti-hyperglycemic effect, metformin is the first-line medication for the treatment of type 2 diabetes, particularly in people who are obese. However, metformin is a drug with a very wide range of pharmacological properties and reports of its therapeutic effect on diseases including inflammation and cancer are increasing. Numerous research groups have reported that metformin has beneficial effects on a variety of inflammatory skin disorders including psoriasis, acanthosis nigricans, acne, hidradenitis suppurativa, and allergic contact dermatitis. According to these reports, in addition to the well-known action of metformin, that is, its anti-hyperglycemic effect, NF-kB inhibition and the resulting alteration to the cytokine network may be the potential targets of metformin. Its anti-hyperandrogenism effect has also been confirmed as the major action of metformin in some inflammatory skin diseases. Moreover, novel regulatory mechanisms, including autophagy and antioxidant processes, have been suggested as promising mechanisms of action for metformin in inflammatory skin disorders.

Therapeutic implications of dermoscopic findings in acanthosis nigricans: A clinical and histopathological study

Acanthosis nigricans is associated with numerous systemic disorders. These include endocrinological conditions such as, diabetes, acromegaly, Cushing's syndrome, thyroid dysfunction, as well as metabolic abnormalities like obesity and polycystic ovarian disease. Its association with visceral malignancy is known. Moreover, Acanthosis nigricans is known to be a cutaneous marker of insulin resistance (IR) and hyperinsulinemia. The primary aim of this study was to study clinical and histopathological patterns of acanthosis nigricans and its correlation with dermoscopic patterns and treatment implications. 103 patients clinically diagnosed as acanthosis nigricans were enrolled in the study. Clinical evaluation, dermoscopy, and skin biopsy was done for histopathological evaluation. Consistency was observed in the changes seen on dermoscopy with clinical and histopathological findings. Common dermoscopy findings were Crista Cutis, Sulcus Cutis, Papillary projections, hyperpigmented dots, crypts, and blotching Dermoscopic findings can be correlated with histopathological features. Dermoscopy allows visualization on higher magnification which helps to pick up subtle changes which are not visible to naked eye. Dermoscopy can be a useful tool to distinguish acanthosis nigricans from other pigmentary disorders in patients who are not willing for histopathological examination and helps in treatment making decisions.

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.

A Lean Lady With Acanthosis Nigricans and Uncontrolled Diabetes Mellitus

A 47-year-old Asian Indian woman presented with uncontrolled hyperglycaemia and osmotic symptoms despite multiple oral antidiabetic medications and insulin. She had a history of recurrent oral ulcers, profound weight loss, and intermittent fever for one and a half years before the presentation. She had severe acanthosis nigricans, although her body mass index (BMI) was 14.6 kg/m².

Her blood glucose remained uncontrolled despite very large dosages of intravenous insulin (more than 12,000 units daily). Evaluation for possible underlying collagen vascular diseases and malignancies were negative. Her serum insulin levels were high. She tested negative for anti-insulin antibodies but positive for anti-insulin-receptor antibodies. She improved with a pulse dose of intravenous methylprednisolone but relapsed within one month. A second pulse dose was given following which a complete remission of diabetes and regression of acanthosis was observed.

Type B insulin resistance, a rare cause of severe insulin resistance, may respond favourably to immunosuppressive therapy with high-dose methylprednisolone.

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 novel heterozygous mutation in the insulin receptor gene presenting with type A severe insulin resistance syndrome

Background Inherited severe insulin resistance syndromes (SIRS) are rare and can be caused by mutations in the insulin receptor gene (INSR). Case presentation A 12-year-old Jamaican girl with a BMI of 24.4 kg/m2 presented with polyuria and polydipsia. A diagnosis of T1DM was made in view of hyperglycaemia (18 mmol/l), and elevated Hba1C (9.9%), and insulin therapy was initiated. Over the next 2 years, she developed hirsutism and acanthosis nigricans, and had minimal insulin requirements with frequent post-prandial hypoglycaemia. In view of this, and her strong family history suggestive of a dominantly inherited type of diabetes, the diagnosis was revisited. Targeted next-generation sequencing (NGS) of the patient's monogenic diabetes genes was performed. What is new? NGS revealed a novel heterozygous missense INSR variant, NM_000208.3:c.3471T>G, p.(His1157Gln), confirming a diagnosis of Type A SIRS. Conclusions Type A SIRS can be difficult to differentially diagnose due to the variable phenotype. Features of insulin resistance may be absent at initial presentation and may develop later during pubertal progress. Awareness of the clinical features and comprehensive genetic testing are essential to identify the condition.

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.

The metabolic salute: A unique presentation of transverse nasal acanthosis nigricans and allergic rhinitis in an obese pediatric patient

Acanthosis nigricans (AN) is a well-known cutaneous condition that is most commonly associated with insulin resistance and obesity when present in a pediatric patient. We present a unique presentation of AN in an adolescent African American girl with a history of perennial allergic rhinitis. She presented with AN affecting the neck, axillae, as well as the transverse nasal crease, a consequence of habitual pushing of the nasal tip upward due to chronic obstruction and itching from allergic rhinitis known as the "allergic salute." All providers should be aware of this rare presentation, as the presence of AN should prompt additional evaluation to determine the underlying cause and effect of appropriate treatment.