Indian Journal of Dermatology
  Publication of IADVL, WB
  Official organ of AADV
Indexed with Science Citation Index (E) , Web of Science and PubMed
Users online: 1915  
Home About  Editorial Board  Current Issue Archives Online Early Coming Soon Guidelines Subscriptions  e-Alerts    Login  
    Small font sizeDefault font sizeIncrease font size Print this page Email this page

Table of Contents 
Year : 2022  |  Volume : 67  |  Issue : 1  |  Page : 92
Estimation of metabolic syndrome in acanthosis nigricans - A hospital based cross-sectional study

Department of Dermatology, KS. Hegde Medical Academy, Nitte (Deemed to be University), Mangalore, Karnataka, India

Date of Web Publication19-Apr-2022

Correspondence Address:
Banavasi S Girisha
Department of Dermatology, KS Hegde Medical Academy, Nitte (Deemed to be University), Deralakatte, Mangalore - 575 018, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijd.ijd_442_21

Rights and Permissions


Background and Objectives: Acanthosis nigricans is characterized by hyperpigmentation and velvet-like thickening of the skin. It symmetrically involves the neck, axilla, groins, antecubital and popliteal fossae, umbilical, and perianal areas. Acanthosis nigricans is a marker for insulin resistance and is increasingly found to be associated with metabolic syndrome. We conducted this study to estimate the frequency of metabolic syndrome in acanthosis nigricans. Methods: In this hospital-based, cross-sectional study, we evaluated 60 patients with acanthosis nigricans with neck involvement. They were examined for other areas of involvement by acanthosis nigricans. Axillary and neck severity was graded based on the scale described by Burke et al. Insulin resistance was interpreted using homeostatic model assessment (HOMA-IR). Metabolic syndrome was diagnosed according to the SAM-NCEP criteria. Collected data were analyzed using IBM SPSS Statistics, Version 22 (Armonk, NY: IBM Corp). Results: Axilla was the most common site involved in 51 patients (85%) followed by knuckles (55%). Metabolic syndrome was found in 78.3% of our patients, and 56.66% had insulin resistance. A statistically significant association of severity grading of axillary acanthosis nigricans with both metabolic syndrome (P = 0.001) and insulin resistance (P = 0.03) was noted. However, no meaningful association was found between the severity grading of neck acanthosis nigricans with both metabolic syndrome (P = 0.4) and insulin resistance (P = 0.08). The association of neck texture grading of acanthosis nigricans with insulin resistance was statistically significant (P = 0.005). Conclusions: Metabolic syndrome was seen in 78.3% of acanthosis nigricans. Axillary severity grading was associated with metabolic syndrome.

Keywords: Acantosis nigricans, HOMA-IR, insulin resistance, metabolic syndrome, SAM-NCEP criteria

How to cite this article:
Philip NE, Girisha BS, Shetty S, Pinto AM, Noronha TM. Estimation of metabolic syndrome in acanthosis nigricans - A hospital based cross-sectional study. Indian J Dermatol 2022;67:92

How to cite this URL:
Philip NE, Girisha BS, Shetty S, Pinto AM, Noronha TM. Estimation of metabolic syndrome in acanthosis nigricans - A hospital based cross-sectional study. Indian J Dermatol [serial online] 2022 [cited 2023 Jun 4];67:92. Available from:

   Introduction Top

Metabolic syndrome is a cluster of risk factors, including obesity, dyslipidemia, hypertension, and glucose intolerance. It is thought to be caused by insulin resistance and altered adipocyte function.[1] Insulin resistance is due to ineffective utilization of produced insulin in the human body, leading to increased production and raised level of plasma insulin. Finally, beta cells of pancreatic islets fail to keep up with the body's increased need for insulin.[2] Without enough active insulin, excess glucose builds up in the bloodstream, leading to prediabetes, diabetes, and many other health disorders. Excess weight and physical inactivity are thought to be significant contributors to the development of insulin resistance.[3]

Acanthosis nigricans is recognized as a reliable cutaneous marker for insulin resistance. Acanthosis nigricans present as velvet-like, brown to black thickening of the skin, which mainly occur in the neck, armpits, antecubital fossae, groin, popliteal fossae, and umbilical region.[4] In reduced frequency, it can also be seen over eyelids, soles of the feet, nipples, palms, and phalanges. Rarely, it can affect the oral mucosa, respiratory mucosa, and genital region.[5] In the year 2000, it was incorporated into the list of indicators for the risk of diabetes by the American Diabetes Association (ADA).[6] A third of South Asia's population is now categorized in the obese category because of lifestyle changes and eating habits. Obesity promotes a subsequent rise in the insulin resistance and metabolic syndrome.[7] Metabolic syndrome is a known risk factor for coronary artery disease; recognizing this early will help in institution of measures to prevent coronary artery disease-associated morbidity and mortality. Very few Indian studies in the literature have addressed the issue of acanthosis nigricans and prevalent metabolic syndrome. Thus, we undertook this study.

   Methods Top

We conducted a cross-sectional study on acanthosis nigricans in a tertiary care hospital. Clinically diagnosed patients with AN with neck involvement attending the Outpatient Department of Dermatology were enrolled in this study during the period from January 2015 to January 2016. Included patients were above the age of 14 years. Exclusion criteria included pregnant women, underlying malignancy, immune-compromised patients, and history of intake of oral contraceptive pills.

The sample size is determined using the formula n = z2pq/d2, where

n = denotes the sample size

z = value of the normal distribution corresponding to a significance level of 0.05 which is 1.96

p = expected proportion in the population = 0.17

q = (1 − p) = 0.83

d = precision = 0.1

N = (1.96)2 × 0.17 × 0.83/(0.1)2 = 54.20

While determining p, we considered the study done in Sri Lanka by Dassanayake et al.[8] who reported a prevalence of 17.4% as the population characteristics of Sri Lanka and our population characteristics are similar we chose this study.

The sample size of 54 thus obtained was rounded off to 60.

The study was started after obtaining the institutional ethical clearance. Informed assent/consent was obtained from all the patients. History of any medical illness and family history of acanthosis nigricans were noted. Thorough physical examination was done in all patients. BP was noted in the sitting position. Waist and hip circumference was measured in a standard manner and the waist-hip ratio was calculated. Body mass index was interpreted according to The Standard Consensus Statement for the Indian population.[9]

Acanthosis nigricans of neck and axilla was graded based on the standard scale as described by Burke et al.,[10] which is as follows

  1. NECK grading-

    • Grade 0: Not visible.
    • Grade 1: Present: clearly present on close visual inspection, not visible to the casual observer, extent not measurable.
    • Grade 2: Mild: limited to the base of the skull, does not extend to the lateral margin of the neck (usually, 3 inches in breadth).
    • Grade 3: Extending to the lateral margins, not visible from the front.
    • Grade 4: Extending anteriorly.

  2. AXILLA grading

    • Grade 0: Absent.
    • Grade 1: Present on close visual examination.
    • Grade 2: Localized to the central portion of axilla
    • Grade 3: Involving the entire axilla.
    • Grade 4: Extends beyond axilla.

  3. Neck texture:

    • Grade 0: Smooth to touch: no differentiation from normal skin to palpation.
    • Grade 1: Rough to touch: clearly differentiated from normal skin.
    • Grade 2: Coarseness can be observed visually, portions of the skin clearly raised above other areas.
    • Grade 3: Extremely coarse: “hills and valleys” observable on visual examination.

Other skin conditions were also noted.

All patients underwent the following laboratory tests after overnight fasting: fasting lipid profile, fasting glucose level, and fasting serum insulin levels. Insulin resistance was estimated and interpreted using the homeostatic model assessment for insulin resistance (HOMA-IR) method for insulin resistance. The formula used was

fasting insulin (μUI/mL) x fasting plasma glucose (mmol/L)/22.5

A HOMA-IR value of ≥2.6 was considered as insulin resistance.

Metabolic syndrome was diagnosed if three or more of the SAM-NCEP criteria were fulfilled. The criteria included abdominal obesity (considered as waist circumference ≥90 cm for males and ≥80 cm for females), blood pressure >130/85 mm Hg, fasting blood glucose ≥100 mg/dl, hypertriglyceridemia >150 mg/dl, or low HDL cholesterol (<40 mg/dl for males and <50 mg/dl for females).

The data collected were entered into a Microsoft Excel spreadsheet and analyzed using IBM SPSS Statistics, Version 22 (Armonk, NY: IBM Corp). Descriptive data for categorical variables were presented as frequency and percentages. Fisher's Exact test was used to test the association between insulin resistance and metabolic syndrome with the study variables. Correlation analysis was done to see any correlation between HOMA-IR and BMI. Regression analysis done see the risk factors for metabolic syndrome in AN patients.

   Results Top

The study included 60 clinically diagnosed cases of acanthosis nigricans with neck involvement. Male:female ratio was found to be 1:1.6. Mean age of the study group was 34 years. Forty-nine patients (81.67%) were clustered between 21 and 50 years of age. Eighteen patients (30%) had family history of acanthosis nigricans. Majority (95%) of patients were found to be in the obese category. Metabolic syndrome was found to be present in 47 patients (78.3%). Insulin resistance as calculated by HOMA-IR was seen in 34 patients (56.66%). A poor correlation was observed between HOMA-IR and BMI (rs = 0.265). Fifty-one patients (85%) had AN over axilla. Thirty-three patients (55%) had AN over the knuckles. Elbow and knee involvement were seen in 16 patients (26.7%) and 9 patients (15%), respectively. The association between the site of involvement with presence of metabolic syndrome and insulin resistance is given in [Table 1]. Association of knuckle involvement with insulin resistance and metabolic syndrome was statistically meaningful. Axillary involvement and knee involvement were significantly associated with metabolic syndrome and insulin resistance, respectively. The association between the severity grading of neck and axilla with metabolic syndrome and insulin resistance is shown in [Table 2] and [Table 3], respectively. There was a statistically meaningful association seen between severity of neck texture and insulin resistance (P = 0.005). Statistically significant association was also seen between the severity grading of the axilla with metabolic syndrome (P = 0.009) and insulin resistance (P = 0.01). When patients with metabolic syndrome are compared with those without, we found the difference in all the components of metabolic syndrome are statistically significant except for HDL and diastolic blood pressure as depicted in [Table 4]. Logistic regression analysis in AN patients revealed that FBS was a risk factor for metabolic syndrome [Table 5].
Table 1: Site of involvement of acanthosis nigricans and frequency of insulin resistance and metabolic syndrome

Click here to view
Table 2: Acanthosis nigricans severity grading and its relation to insulin resistance

Click here to view
Table 3: Acanthosis nigricans severity grading and its relation to metabolic syndrome

Click here to view
Table 4: Characteristics of acanthosis nigricans patients with metabolic syndrome and without metabolic syndrome

Click here to view
Table 5: Logistic regression for factors influencing metabolic syndrome in the study population

Click here to view

Comorbidities seen were asthma (13.3%), thyroid disorder (11.7%), hypertension (10%), PCOD (8.3%), and diabetes mellitus (6.7%). In this study, acrochordons were seen in 21 patients (35%). We found significant association of acrochordons with metabolic syndrome (P = 0.0007) and insulin resistance (P = 0.005) in our patients. Hirsutism (16.7%), pityriasis versicolor (13.3%), acne (10%), seborrheic dermatitis (6.7%), xerosis (8.3%), and allergic contact dermatitis (5%) were the other cutaneous lesions seen.

   Discussion Top

Insulin resistance is the reduced sensitivity or responsiveness of the human body to the metabolic actions of insulin. When people have insulin resistance, glucose increases in the blood instead of being absorbed by the cells, leading to a prediabetes state or type 2 diabetes mellitus.[4] Thirty-four (56.7%) of our patients were shown to have insulin resistance. We found that knuckle and knee involvement were significantly associated with insulin resistance. We also noted that neck texture severity grading [Figure 1]a,[Figure 1]b,[Figure 1]c and axillary severity grading [Figure 2]a,[Figure 2]b,[Figure 2]c were significantly associated with insulin resistance. Atwa et al.[11] found that 65.4% of AN patients had insulin resistance and 15.4% of patients had diabetes mellitus. They opined that AN may be clinical marker to identify individuals with high risk for type 2 diabetes mellitus. A study on overweight Hispanic children by Kobaissi et al.[12] found that AN was an independent risk factor for insulin resistance. This study opined that body fat is primarily responsible for insulin resistance and AN grading is of little help in clinical assessment of the severity of insulin resistance. They used combined neck grading and texture scoring described by Burke et al. and excluded the axillary grading.[12] However, we have to take into account the fact that our study subjects were mostly adults while their study was on children. In an Indian study by Patidar et al.[13] on diabetic patients, a significant association of neck grading [Figure 3]a,[Figure 3]b,[Figure 3]c with insulin resistance was found. However, there was no association with axillary grading and insulin resistance, which had a significant association in our study.
Figure 1: (a) Neck texture severity grade 1 (b) Neck texture severity grade 2 (c) Neck texture severity grade 3

Click here to view
Figure 2: (a) Axilla severity grade 2 (b) Axilla severity grade 3 (c) Axilla severity grade 4

Click here to view
Figure 3: (a) Neck severity grade 2 (b) Neck severity grade 3 (c) Neck severity grade 4

Click here to view

The overall prevalence of MS identified with SAM-NCEP criteria among Asian Indians is 30%–40%, which is almost double that of the 15%–20% prevalence in Europeans.[5] Metabolic syndrome has been found to be associated with various dermatological conditions such as psoriasis, androgenetic alopecia, lichen planus, acne vulgaris, and hidradenitis suppurativa.[14],[15],[16],[17],[18] We found MS in 78.3% of our patients with AN. We also found that AN patients are at risk for almost all components of metabolic syndrome. Dassanayake et al.[8] found that the prevalence of AN in 17.4% and metabolic syndrome in 34.8% of participants in the Sri Lankan urban population. They noted that AN patients were at risk for all the components of MS which was diagnosed on the basis of the ATP III criteria. They concluded that AN could not be a screening test for MS because of its low sensitivity; however, it could predict the presence of MS because of its high specificity. Obese women with AN appear to be at higher risk for metabolic syndrome. In our study, out of 37 women, 34 were found to be in obese category (BMI > 25 kg/m2); among them, metabolic syndrome was present in 57.4%. In a study by Ayaz et al.[19] done on 250 obese women, 100 patients had acanthosis nigricans, and metabolic syndrome was seen in 60 (60%) of the patients, which was comparable to our study. We observed that the association of metabolic syndrome with knuckle [Figure 4] and axillary involvement was statistically meaningful. Axillary severity grading was also significantly associated with metabolic syndrome (P = 0.001). We suggest examining the axilla, knuckle, and knee [Figure 5] for acanthosis nigricans when confronted with patient with acanthosis nigricans affecting the neck. The severity of axillary acanthosis nigricans should also be assessed. We believe this will help in recognizing the underlying insulin resistance and metabolic syndrome.
Figure 4: Acanthosis nigricans of knuckles

Click here to view
Figure 5: Acanthosis nigricans of knees

Click here to view


No control arm in our study due to financial constraints to do the investigations in matched healthy subjects.

As this is a hospital-based study rather than a community-based study, the results cannot be extrapolated to the general population.

We did not evaluate axillary acanthosis nigricans alone. All of our axillary acanthosis nigricans patients had neck involvement also. This might have affected the outcome.

   Conclusion Top

Metabolic syndrome was seen in 78.3% of acanthosis nigricans.

Axillary severity grading was associated with metabolic syndrome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Enas EA, Mohan V, Deepa M, Farooq S, Pazhoor S, Chennikkara H. The metabolic syndrome and dyslipidemia among Asian Indians: A population with high rates of diabetes and premature coronary artery disease. J Cardiometab Syndr 2007;2:267-75.  Back to cited text no. 1
Fagot-Campagna A, Narayan KMV, Imperatore G. Type 2 diabetes in children. BMJ 2001;322:377-8.  Back to cited text no. 2
Wilcox G. Insulin and insulin resistance. Clin Biochem Rev 2005;26:19-39.  Back to cited text no. 3
Higgins SP, Freemark M, Prose NS. Acanthosis nigricans: A practical approach to evaluation and management. Dermatol Online J 2008;14:2.  Back to cited text no. 4
Rogers DL. Acanthosis nigricans. Semin Dermatol 1991;10:160-3.  Back to cited text no. 5
Barbato MT, Criado PR, Silva AK, Averbeck E, Guerine MB, Sá NB. Association of acanthosis nigricans and skin tags with insulin resistance. An Bras Dermatol 2012;87:97–104.  Back to cited text no. 6
Araújo LMB, Viveiros AMC, Lopes RC, Viana AC, Fukui RT. Acanthosis nigricans in obese women in a mixed-race population: A marker of metabolic disturbances. An Bras Dermatol 2002:77:537-43.  Back to cited text no. 7
Dassanayake AS, Kasturiratne A, Niriella MA, Kalubovila U, Rajindrajith S, De Silva AP, et al. Prevalence of Acanthosis nigricans in an urban population in Sri Lanka and its utility to detect metabolic syndrome. BMC Res Notes 2011;4:25.  Back to cited text no. 8
Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India 2009;57:163–70.  Back to cited text no. 9
Burke JP, Hale DE, Hazuda HP, Stern MP. A quantitative scale of acanthosis nigricans. Diabetes Care 1999;22:1655–9.  Back to cited text no. 10
Atwa M, Emara A, Balata M, Youssef N, Bayoumy N, Sherif A, et al. Serum leptin, adiponectin, and resistin among adult patients with acanthosis nigricans: Correlations with insulin resistance and risk factors for cardiovascular disease. Int J Dermatol 2014;53:e410–20.  Back to cited text no. 11
Kobaissi HA, Weigensberg MJ, Ball GDC, Cruz ML, Shaibi GQ, Goran MI. Relation between Acanthosis nigricans and insulin sensitivity in overweight Hispanic children at risk for type 2 diabetes. Diabetes Care 2004;27:1412–6.  Back to cited text no. 12
Patidar PP, Ramachandra P, Philip R, Saran S, Agarwal P, Gutch M, et al. Correlation of acanthosis nigricans with insulin resistance, anthropometric, and other metabolic parameters in diabetic Indians. Indian J Endocrinol Metab 2012;16:436-7.  Back to cited text no. 13
Madanagobalane S, Anandan S. Prevalence of metabolic syndrome in south Indian patients with psoriasis vulgaris and the relation between disease severity and metabolic syndrome: A hospital-based case-control study. Indian J Dermatol 2012;57:353-7.  Back to cited text no. 14
[PUBMED]  [Full text]  
Bakry OA, Shoeib MA, El Shafiee MK, Hassan A. Androgenetic alopecia, metabolic syndrome, and insulin resistance: Is there any association? A case-control study. Indian Dermatol Online J 2014;5:276–81.  Back to cited text no. 15
Hashba H, Bifi J, Thyvalappil A, Sridharan R, Sreenivasan A, Mathew P. Prevalence of metabolic syndrome in patients with lichen planus: A cross-sectional study from a tertiary care center. Indian Dermatol Online J 2018;9:304–8.  Back to cited text no. 16
[PUBMED]  [Full text]  
Nagpal M, De D, Handa S, Pal A, Sachdeva N. Insulin resistance and metabolic syndrome in young men with acne. JAMA Dermatol 2016;152:399–404.  Back to cited text no. 17
Sabat R, Chanwangpong A, Schneider-Burrus S, Metternich D, Kokolakis G, Kurek A, et al. Increased prevalence of metabolic syndrome in patients with acne inversa. PLoS One 2012;7:e31810.  Back to cited text no. 18
Ayaz T, Baydur Şahin S, Şahin OZ. Relation of Acanthosis nigricans to metabolic syndrome in overweight and obese women. Metab Syndr Relat Disord 2014;12:320–3.  Back to cited text no. 19


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


Print this article  Email this article
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Article in PDF (1,551 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

    Article Figures
    Article Tables

 Article Access Statistics
    PDF Downloaded13    
    Comments [Add]    

Recommend this journal