Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

initial presentation with underlying cause

1st line – treatment of underlying disorder

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ONGOING
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initial presentation with underlying cause
1st line – 

treatment of underlying disorder

In most cases, treatment should be directed at the underlying cause, such as obesity, hyperinsulinemia, or malignancy.[2]​​ Acanthosis nigricans usually regresses with treatment of the underlying disorder.

unresolved despite treatment of underlying cause, or hereditary or idiopathic

1st line – topical therapy

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unresolved despite treatment of underlying cause, or hereditary or idiopathic
1st line – 

topical therapy

For patients with familial acanthosis nigricans (AN), genetic syndromes, or idiopathic AN with no identifiable underlying cause, direct treatment of the lesions is indicated; but treatment is usually elective, and it is not necessary to treat lesions acutely. Treatment with topical agents is typically the first choice, although only small case studies and series have been reported.[2]​​[21][36]​​​[37][42]​​​

Primary options

ammonium lactate topical: (12%) apply sparingly to the affected area(s) twice daily

OR

tretinoin topical: (0.05 to 0.1%) apply sparingly to the affected area(s) once daily at bedtime

OR

calcipotriene topical: (0.005%) apply sparingly to the affected area(s) twice daily

2nd line – oral therapy

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ONGOING
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unresolved despite treatment of underlying cause, or hereditary or idiopathic
2nd line – 

oral therapy

Oral therapy is used for patients who are not likely to comply with topical treatments, or if topical treatments have failed. Some patients with hyperandrogenism, insulin resistance, and acanthosis nigricans (HAIR-AN) respond well to metformin combined with a weight-loss regimen.[43]

Metformin should be avoided or used with caution in patients with renal impairment. It is contraindicated when eGFR is <30 mL/minute/1.73 m². Initiating treatment with metformin is not recommended in patients with an eGFR between 30 to 45 mL/minute/1.73 m²; however, in patients already on metformin with an eGFR that falls to <45 mL/minute/1.73 m², assess the risks and benefits of continuing treatment and discontinue metformin if their eGFR falls below 30 mL/minute/1.73 m². Metformin should also be discontinued in: patients undergoing imaging with iodinated contrast medium who have an eGFR between 30 to 60 mL/minute/1.73 m²; patients with a history of liver disease, heart failure, or alcoholism; or patients who are to be given intra-arterial iodinated contrast.

In the US, isotretinoin distribution is limited to iPLEDGE providers to minimize fetal exposure.

Counseling about pregnancy avoidance and the use of two methods of birth control for one month prior to treatment, throughout the treatment course, and for one month after treatment is terminated, is mandatory for women taking isotretinoin. For patients taking acitretin, pregnancy avoidance is required for >3 years after treatment is discontinued. It should only be used by physicians experienced with systemic retinoids and with teratogenicity knowledge.

Primary options

isotretinoin: 0.5 to 1 mg/kg/day orally given in 2 divided doses

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OR

metformin: 500-1000 mg orally twice daily

OR

octreotide: 50 micrograms subcutaneously three times daily

OR

acitretin: 25-50 mg orally once daily

3rd line – laser therapy

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ONGOING
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unresolved despite treatment of underlying cause, or hereditary or idiopathic
3rd line – 

laser therapy

Laser is an emergent approach in the treatment of acanthosis nigricans, but appears to be effective.[38]​ It may be considered in patients with extensive, disfiguring, or cosmetically unacceptable lesions that are unresponsive to topical or oral therapy. In darker skin types, there is a significant risk of post-treatment hypopigmentation. Types of laser treatment that have been reported include: long-pulsed (5 ms) Alexandrite laser: 10 sessions at 4- to 8-week intervals at 16 to 23 J/cm² with spot size of 10 or 12.5 mm and continuous-wave CO₂ laser: 3 sessions at 15 W at 4- to 6-week intervals.[39][40]

4th line – surgery

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ONGOING
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unresolved despite treatment of underlying cause, or hereditary or idiopathic
4th line – 

surgery

For patients with large, disfiguring lesions that are unresponsive to other treatments, surgical excision may be considered as a last resort. Lesions on the eyelid with functional impairment have also been effectively removed by surgery.[41]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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