What teaching information should be provided to parents of an overweight 4-year-old child with acanthosis nigricans (a skin condition characterized by dark, velvety skin patches) on physical examination?

From the Guidelines

I strongly recommend focusing on healthy lifestyle changes for your 4-year-old child with acanthosis nigricans, which is a skin condition that appears as dark, velvety patches typically in body folds and often indicates insulin resistance. Start by gradually improving your child's diet with more fruits, vegetables, and whole grains while reducing sugary drinks, processed foods, and excessive carbohydrates. Aim for 60 minutes of active play daily, broken into shorter periods throughout the day. Limit screen time to no more than 1 hour per day of quality programming. Establish regular sleep routines, as 4-year-olds need 10-13 hours of sleep daily. Make changes as a family to provide better support and modeling. Regular medical follow-up is important to monitor your child's growth and the acanthosis nigricans. These skin changes occur because higher insulin levels stimulate skin cells to grow more rapidly, causing the darkened, thickened skin patches. As insulin levels normalize through lifestyle changes, the skin condition often improves. Weight management at this age should focus on slowing weight gain while allowing normal height growth, not weight loss. Patience is key, as improvements in both weight status and skin appearance may take several months to become noticeable.

Key Recommendations

• Gradually improve diet with more fruits, vegetables, and whole grains
• Reduce sugary drinks, processed foods, and excessive carbohydrates
• Aim for 60 minutes of active play daily
• Limit screen time to no more than 1 hour per day
• Establish regular sleep routines
• Make changes as a family to provide better support and modeling
• Regular medical follow-up to monitor growth and acanthosis nigricans

According to the most recent and highest quality study, 1, distinguishing between type 1 and type 2 diabetes in children can be difficult, and overweight and obesity are common in children with type 1 diabetes. However, the presence of islet autoantibodies has been associated with faster progression to insulin deficiency. Therefore, it is essential to focus on healthy lifestyle changes to improve insulin sensitivity and reduce the risk of developing type 2 diabetes. Additionally, studies such as 1 and 1 provide guidance on promoting healthy lifestyles in children, including reducing sedentary activities, limiting screen time, and encouraging physical activity. The expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents also recommends identifying children at high risk for obesity and providing focused diet and physical activity education 1.

From the Research

Overview of Acanthosis Nigricans

• Acanthosis nigricans is a cutaneous disorder characterized by symmetric velvety hyperpigmented plaques on intertriginous areas like axilla, neck, inframammary, and groin 2.
• It can be a cutaneous manifestation of a variety of systemic disorders and, rarely, as a sign of internal malignancy 3.
• Obesity is the most common cause of acanthosis nigricans, which is increasingly observed in obese children and adolescents and can serve as a cutaneous marker of insulin resistance 3, 2.

Diagnosis and Evaluation

• The diagnosis is mainly clinical, based on the characteristic appearance and the typical sites of the lesions 3.
• Homeostasis model assessment-insulin resistance (HOMA-IR) is a good tool for assessment of insulin resistance 2.

Management and Treatment

• 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, and lasers 2, 4.
• Weight reduction is the most scientific and practical management strategy 2.
• Metformin has been shown to reduce hyperinsulinaemia, body weight, and fat mass and improve insulin sensitivity in patients with insulin resistance and acanthosis nigricans 5, 4.
• Other treatment options include isotretinoin, rosiglitazone, octreotide, and vitamin D analogs, although the evidence for these treatments is limited to case reports and small clinical trials 6, 4.

Considerations for Parents of Overweight 4-Year-Old with Acanthosis Nigricans

• Early recognition of acanthosis nigricans is important because it can be a sign of underlying insulin resistance and other systemic disorders 3.
• Parents should work with their child's healthcare provider to develop a treatment plan that addresses the underlying cause of the acanthosis nigricans, as well as any related health issues 3, 2.
• Lifestyle changes, such as a healthy diet and regular exercise, can help with weight reduction and improve insulin sensitivity 2.