What is the treatment for acanthosis nigricans?

Treatment of Acanthosis Nigricans

The primary treatment of acanthosis nigricans is addressing the underlying cause—weight reduction for obesity-related cases, discontinuation of causative medications, treatment of endocrinopathies, or management of underlying malignancy—with topical retinoids serving as first-line therapy for cosmetic improvement of the skin lesions themselves. 1

Treatment Algorithm

Step 1: Address the Underlying Cause (Primary Treatment)

The most critical intervention is treating the root cause, as this can lead to resolution and prevent recurrence of acanthosis nigricans 1:

• Obesity-related AN: Weight reduction is essential, as obesity is the most common cause and is linked to insulin resistance 1
• Drug-induced AN: Discontinue the causative medication 1
• Endocrine disorders: Treat underlying endocrinopathy (diabetes, insulin resistance, hormonal disorders) 1, 2
• Malignancy-associated AN: Treat the underlying malignancy 1

Step 2: Topical Therapy for Cosmetic Improvement

When the underlying cause is not amenable to treatment or for isolated lesions requiring cosmetic improvement 1:

First-Line Topical Treatment

• Topical retinoids are the first-line therapy for hyperpigmented plaques, though skin irritation is the main limiting factor 3, 1, 4
• Tretinoin has been used with limited success for reducing plaque thickness and hyperpigmentation 4

Alternative Topical Agents

• Vitamin D analogs (calcipotriol) have shown some limited success 1, 4
• Keratolytic agents help reduce hyperkeratosis, which is the main concern leading to skin darkening 3, 2
• Alpha hydroxy acids can improve cosmesis and reduce plaque thickness 2
• Chemical peels are often used for localized lesions 1

Special Anatomical Considerations

• Periocular AN: Apply topical agents carefully to avoid eye irritation 5
• Hands and forearms: Longer courses of topical therapy may be needed due to thicker skin in these areas 5

Step 3: Combination Therapy Approaches

Combinational therapies have emerged to combat the skin irritation limitation of retinoid monotherapy 3:

• Combining retinoids with other agents can improve tolerability while maintaining efficacy 3
• The specific combinations should be tailored to reduce irritation while addressing both hyperkeratosis and hyperpigmentation 3

Step 4: Systemic and Advanced Therapies

For extensive, generalized, or treatment-resistant cases 1:

• Oral retinoids may be considered for extensive or generalized AN unresponsive to topical therapy 1
• Dermabrasion is an uncommon treatment modality 1
• Laser therapy can be considered in select cases 1, 4
• Surgical removal is rarely used 1, 4

Important Clinical Pitfalls

• Complete cure is difficult to achieve: Even with treatment, acanthosis nigricans may not fully resolve, making management of expectations important 1
• Recurrence prevention: The underlying cause must be treated to prevent recurrence 1
• Quality of life considerations: While treating the primary cause is the goal, cosmetic resolution can be important for patients' quality of life 6
• Diagnosis confirmation: The diagnosis is mainly clinical based on symmetric, hyperpigmented, velvety plaques in intertriginous areas, but atypical presentations may require further evaluation 1
• Screen for systemic disease: Early recognition is crucial as AN can be a cutaneous marker of insulin resistance or, rarely, internal malignancy 1