What is the treatment for acanthosis nigricans?

Treatment of Acanthosis Nigricans

Treat the underlying cause first—weight reduction for obesity-associated acanthosis nigricans is the most effective intervention, followed by topical tretinoin as first-line skin-directed therapy for cosmetic improvement. 1, 2

Primary Management Strategy

Address the underlying etiology:

• Weight reduction is the most scientific and practical management strategy for obesity-associated acanthosis nigricans, which is the most common form 1
• Discontinue causative medications if drug-induced 3
• Treat underlying endocrinopathies (insulin resistance, diabetes, thyroid disorders) 3, 4
• Evaluate for and treat internal malignancy in malignant acanthosis nigricans 3
• Use HOMA-IR (Homeostasis Model Assessment-Insulin Resistance) to assess insulin resistance 1

Skin-Directed Treatment Algorithm

First-Line Topical Therapy

Topical tretinoin receives the strongest recommendation (Grade A evidence) for direct treatment of acanthosis nigricans lesions 2

• Topical retinoids are first-line therapy for hyperpigmented plaques 5
• The main limiting factor is skin irritation, which has led to development of combination approaches 5

Second-Line Topical Options (Grade B Evidence)

When tretinoin causes excessive irritation or as alternatives: 2

• Adapalene gel (better tolerated retinoid alternative)
• Urea cream (keratolytic effect)
• Vitamin D analogs (calcipotriol) 1, 3
• Other keratolytics (salicylic acid, lactic acid) 1, 3

Combination Therapy Approach

Combinational therapies are increasingly used to reduce retinoid-associated irritation while maintaining efficacy 5

• Retinoids combined with keratolytics or vitamin D analogs
• This approach addresses both hyperkeratosis and hyperpigmentation while minimizing side effects 5

Advanced Treatment Modalities

Chemical Peels

• Trichloroacetic acid (TCA) peels for localized lesions 1, 3
• Particularly useful for cosmetic improvement in treatment-resistant cases 1

Laser Therapy (Grade B Evidence)

Fractional CO2 laser receives Grade B recommendation 2

• Long-pulsed alexandrite laser 1
• Fractional 1550-nm erbium fiber laser 1
• CO2 laser 1
• Consider for extensive or refractory cases 1

Systemic Therapy

Reserve oral retinoids for extensive or generalized acanthosis nigricans unresponsive to topical therapy 3

• Insulin sensitizers (metformin) when insulin resistance is present 1
• Systemic retinoids for widespread disease 1, 3

Rarely Used Interventions

• Dermabrasion 3
• Surgical removal 3

Location-Specific Considerations

Periocular acanthosis nigricans requires careful application of topical agents to avoid eye irritation 6

Hands and forearms may require longer courses of topical therapy due to thicker skin 6

Critical Caveats

Complete cure and disappearance of lesions are difficult to achieve—set realistic expectations with patients 1, 3

• Treatment is primarily for cosmetic improvement and quality of life 3, 4
• Recurrence is common if the underlying cause is not addressed 3
• Acanthosis nigricans is a treatable but rarely curable condition 1

The psychological impact is significant, particularly in skin of color individuals—cosmetic treatment is justified even when underlying causes cannot be fully addressed 2

Treatment Selection Based on Disease Extent

For localized lesions:

• Start with topical tretinoin or adapalene 2
• Add keratolytics if needed 1, 3
• Consider chemical peels for resistant cases 1

For extensive or generalized disease:

• Aggressive treatment of underlying cause 3
• Topical therapy to affected areas 3
• Consider systemic retinoids if topical therapy fails 3
• Laser therapy for selected areas 1, 2