Tripe palm and malignant acanthosis nigricans in metastatic endometrial adenocarcinoma

INTRODUCTION

Acanthosis nigricans (AN) is a well-recognized cutaneous marker that may signal underlying endocrine dysfunction or, less commonly, internal malignancy. The sudden onset of extensive AN with features such as tripe palms strongly suggests a paraneoplastic process. Prompt recognition of these dermatologic clues is essential, as they can precede the diagnosis of an underlying carcinoma.

CASE REPORT

A dermatology referral was sought for a 57-year-old female with metastatic endometrial adenocarcinoma. She had noticed a generalized textural and pigmentary change in her skin for the last 6 months. On examination, there were thin, velvety, hyperpigmented plaques over the forehead, sides of the face, neck, upper chest, and axillae [Figure 1]. Bilateral palms showed diffuse yellowish thickening and markedly accentuated palmar creases [Figure 2], suggestive of Tripe palms. Histopathological examination of the palm shows hyperkeratosis, papillomatosis, and mild acanthosis with prominent basilar pigmentation [Figure 3]. She had minimal thickening of the soles. Mucosae were within normal limits. The patient was thinly built. She had no other comorbidities and was not on any long-term medications. She denied a similar family history. The onset of the skin lesions preceded the diagnosis of the malignancy by 1 month. A clinical diagnosis of generalized acanthosis nigricans with palmar acanthosis nigricans was made (Tripe palm). The patient was prescribed urea-based emollients and referred back to the oncology team, where she continues to follow up.

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Figure 1:

Image showing thin, velvety, hyperpigmented plaques over the forehead, sides of the face, neck.

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Figure 2:

Palm showing diffuse yellowish thickening and markedly accentuated palmar creases suggestive of Tripe palm.

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Figure 3:

Histopathological examination of palm shows hyperkeratosis, papillomatosis, and mild acanthosis with prominent basilar pigmentation (Hematoxylin and Eosin, 10X).

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DISCUSSION

Acanthosis nigricans (AN) is commonly identified by symmetrical velvety hyperpigmented plaques in intertriginous regions such as the axilla, neck, inframammary, and groin.¹ It has two subtypes, benign and malignant, each having distinct underlying disease mechanisms. The benign form of acanthosis nigricans can be triggered by genetic and endocrine factors, obesity, and specific medications that result in elevated insulin levels.² Malignant acanthosis nigricans is a paraneoplastic syndrome associated with internal malignancies, notably gastric adenocarcinomas (55%–61%), and with carcinomas of the lungs, ovaries, breasts, kidneys, prostate, or bladder.^3,4 It is sudden onset, widespread, and has a progressive course. It can affect both the skin and mucous membranes. It may be associated with the development of skin tags (acrochordons), oral papillomatosis, multiple seborrheic keratoses (Leser-Trélat sign), and palmoplantar acanthosis nigricans (Tripe palm).⁵

In our patient, the progressive course and large extent, along with the involvement of unusual sites like palms, made us suspect malignancy-associated AN.

Exact pathogenesis is unknown, but it is proposed that specific cytokines produced by the tumor, such as transforming growth factor alpha, insulin-like growth factor 1, and fibroblast growth factor, contribute to the development of acanthosis nigricans by stimulating keratinocytes, melanocytes, and fibroblasts.

The histological characteristics of malignant AN lack specificity and show hyperkeratosis and papillomatosis, along with varying degrees of acanthosis.⁶

Management is often symptomatic, as skin largely only shows improvement with treatments directed at the underlying tumor, including surgical resection, chemotherapy, and radiotherapy.⁷ Other treatments that have been tried with mild success are cyproheptadine, psoralen, and ultraviolet A.⁴

CONCLUSION

In conclusion, the presented case of a 57-year-old female with metastatic endometrial adenocarcinoma and associated AN, particularly Tripe palms, highlights the importance of recognizing cutaneous manifestations as potential paraneoplastic syndromes. The atypical presentation involving palms and extensive involvement prompted suspicion of malignancy-associated AN. While the exact pathogenesis remains unclear, cytokines from the tumor may contribute to AN development. Histologically nonspecific, management primarily addresses the underlying malignancy, with limited skin-specific interventions. The case underscores the intricate interplay between dermatological manifestations and systemic conditions, emphasizing the significance of interdisciplinary collaboration in providing comprehensive patient care. Continued oncology follow-up remains crucial for this patient.