Thick skin with a sinister cause

This is malignant acanthosis nigricans in a man in his 80s (fig 1). He presented with a 10 day history of upper abdominal pain preceded by two months of itchy, thickened, and hyperpigmented lesions on his face, neck, chest, and extensor surfaces of the limbs. On physical examination, diffuse velvety skin lesions and seborrhoeic keratoses were evident. This appearance, known as the Leser-Trelat sign, is characteristic of malignant acanthosis nigricans.1 Acanthosis nigricans is characterised by velvety, hyperpigmented, papillomatous lesions, usually in skin flexures and associated with obesity or insulin resistance.2 Rarely, acanthosis nigricans can be associated with internal malignancy.3 When associated with malignancy, acanthosis nigricans may develop more rapidly than with non-malignant causes, and skin lesions can occur in unusual sites such as the oral cavity, palms, and soles.13bmj;381/apr20_7/e073424/F1F1f1Fig 1



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