Download rajiv gandhi university of health sciences, karnataka, bangalore

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1.
Name of the Candidate
(in block letters)
Dr. VINITHA .L
D/O M.S. LOKESH
# 147, 4th CROSS, 2nd STAGE,
AREKERE MICO LAYOUT,
BANERGHATA ROAD,
BANGALORE – 560076.
KARNATAKA.
Name of the Institution
J.J.M. MEDICAL COLLEGE,
and Address
2.
DAVANGERE - 577 004. KARNATAKA
3.
Course of study and subject
MEDICAL – POSTGRADUATE DEGREE
M.D. IN DERMATOLOGY,
VENEREOLOGY AND LEPROLOGY
4.
Date of Admission to course
10-06-2013
5.
Title of the Topic
6.
Brief Resume of the intended work :
“CLINICO-EPIDEMIOLOGICAL STUDY
OF ACANTHOSIS NIGRICANS”
6.1 Need for the study :
Acanthosis nigricans heralds disorders ranging from endocrinologic
disturbances to malignancy. It being an incidental finding, proper diagnosis helps in
early recognition of these conditions and further prevention of disease progression.
The epidemiology of acanthosis nigricans has not been fully understood and
being asymptomatic this condition is often neglected and under diagnosed. There is
paucity of medical literature on clinical and epidemiological aspects of acanthosis
nigricans in Karnataka despite the predisposing factors being present in abundance.
Hence this study has been undertaken to know the demographic features,
clinical patterns and associated conditions in patients suffering from acanthosis
nigricans for prompt diagnosis and initiation of therapy.
1
6.2 Review of literature :
Acanthosis nigricans (AN) is a dermatosis characterized by velvety,
papillomatous,
brownish-black,
hyperkeratotic
plaques,
typically
on
the
intertriginous surfaces and neck.1
It is classified into four types by Curth et al: 2
(a) Malignant acanthosis nigricans (Type I) - a cutaneous paraneoplastic
syndrome associated usually with adenocarcinoma of the stomach, but other
tumours are sometimes found, including those of oesophagus, rectum,
bronchus, urinary tract, ovary, bile duct and thyroid.3
(b) True benign acanthosis nigricans (Type II) - familial, present at birth or
beginning in childhood.
(c) Pseudo- acanthosis nigricans (Type III) - associated with several syndromes
in which obesity and endocrinopathies especially the insulin resistant state
coexist. The term ‘pseudo’ is obsolete now as it differs only in degree from
other forms.
(d) Drug induced acanthosis nigricans (Type IV).
Acanthosis nigricans has a variety of causes, whose likely common
mechanism is stimulation of tyrosinase kinase growth factor receptor signaling
pathways in epidermis.4 The exact incidence of acanthosis nigricans is unknown. Its
much more common in people with darker skin pigmentation.
In a study on
unselected population of 1412 children by Stuart et al, the changes of acanthosis
nigricans was present in 7.1%. 5
The essential clinical features are common to all forms of disease, but vary in
distribution and degree. The sites most commonly involved are the axilla, nape of
the neck, the anogenital region and the groins, but the other flexures, the
submammary region, the umbilicus and, in some cases, almost the entire skin may
be affected. The affected sites show thickening of the skin, accentuation of skin
lines with surface becoming mammilated and rugose. Distal extremities are usually
2
spared. Involvement of mucous membranes is uncommon, but oral mucous
membrane may show delicate velvety furrows.6
Hyperpigmented plaques over elbows, knuckles, knees, and dorsal feet, but
sparing flexures in dark skinned individuals has been suggested as an acral variant
of acanthosis nigricans.7
Acanthosis nigricans is graded on a standard scale of 0-4 as described by
Burke et al.8
1. Neck grading
 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
 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.
Benign acquired acanthosis nigricans occurs as a complication of obesity, it is
seen most often in adults but also occurs in children.9,10 Small patches of
pigmentation and velvety thickening, often with multiple skin tags, are present in
body folds especially axilla, groins and natal cleft. Stuart et al examined 1412
unselected American high school children and found acanthosis nigricans in
3
7%,which correlated well with severe obesity.5 It is associated with various
disorders such as insulin resistant diabetes mellitus, hypothyroidism, SteinLevanthal syndrome, Addison’s disease, pinealoma, gigantism, acrochordons.
HAIR-AN syndrome is a triad of hyperandrogenism,insulin resistance and
acanthosis nigricans in women.11 It may be seen with insulin resistance of various
causes. The finding of pubic hair before the age of 8 years with acanthosis nigricans
was associated with insulin resistance.
Autoimmune acanthosis nigricans may occur in autoimmune diseases,
including SLE, due to antibodies to the insulin receptor.12
Improvement of the skin lesions is often the patient's primary concern. No
randomized, controlled trials exist for any treatment of acanthosis nigricans. No
treatment of choice exists. The goal of therapy is to correct the underlying disease
process. A case of hereditary benign acanthosis improved dramatically with
etretinate.13 Alexandrite laser was successfully used by Rosenbach et al.14
6.3 Objectives of the study :
 To study the clinical characteristics of acanthosis nigricans.
 To know the epidemiological profile of patients presenting with acanthosis
nigricans.
 To know the conditions associated with acanthosis nigricans.
7.
Material and Methods :
7.1 Source of data :
All patients with characteristic clinical manifestations of acanthosis nigricans
attending the Dermatology outpatient department and various wards of Chigateri
General Hospital and Bapuji Hospital attached to J.J.M Medical college,
Davangere.
7.2. Method of collection of data (including sampling procedure if any):
Data will be collected from November 2013 to October 2015 with a minimal
4
sample size of 100 patients.
Informed consent will be taken from every patient enrolled in the study.
A detailed history and clinical examination will be carried out in every patient.
Acanthosis nigricans will be graded based on the standard scale of 0-4 as
described by Burkhe et al.8
The following parameters will be measured using flexible non elastic tape by a
single observer:
 Height
 Weight
 Waist circumference (midway between iliac crest and lower margin of the
ribs)
 Hip circumference (maximum circumference of the buttocks)
The body mass index (BMI) will be calculated by weight in kilograms
divided by height in metres squared.
Fasting glucose level will be estimated.
Statistical analysis: Data will be subjected for appropriate statistical analysis.
Inclusion criteria:
 All age groups and both sexes.
 Patients who have not taken treatment before.
 Those who have given consent for enrolment in the study, from self or
parents.
Exclusion criteria:
 Pregnancy.
 Postpartum period of 1 year.
 Patients previously treated for acanthosis nigricans.
 Patients who are not willing to be a part of the study.
7.3 Does the study require any investigations or interventions to be conducted
on patients or other humans or animals? If so, please describe briefly.
5
Yes
Investigations are required only on patients.

Blood investigation- fasting blood sugar.

Investigations that may be required depending on the presenting
symptoms include:
o Blood: lipid profile , T3,T4,TSH
o USG abdomen
o Other relevant investigations that may be required.
7.4. Has ethical clearance been obtained from your institution in case of 7.3?
Yes
6
8.
References :
1. Higgins SP, Freemark M, Prose NS. Acanthosis nigricans: A practical
approach to evaluation and management. Dermatol Online J 2008; 14(9):2.
2. Curth HO. Classification of acanthosis nigricans.Int J Dermatol
1976;
15:592.
3. Schwartz RA. Acanthosis nigricans. J Am Acad Dermatol 1994; 31: 1–19.
4. Torley D, Bellus GA, Munro CS. Genes, growth factors and acanthosis
nigricans. Br J Dermatol 2002; 147: 1096–101.
5. Stuart CA, Pate CJ, Peters EJ: Prevalence of acanthosis nigricans in an
unselected population. Am J Med 1989; 87: 269 –272.
6. Pindborg JJ, Gorlin RJ. Oral changes in acanthosis nigricans(juvenile type).
Acta Derm Venereol (Stockh) 1961; 42:63.
7. Schwartz RA. Acral acanthosis nigricans (acral acanthotic anomaly). J Am
Acad Dermatol 2007; 56: 349–50.
8. Burke JP, Hale DE, Hazuda HP, Stern MP. A quantitative scale of
acanthosis nigricans. Diabetes Care 1999; 22: 1655-9.
9. Hud JAJ, Cohen JB, Wagner JM, Cruz PD Jr. Prevalence and significance of
acanthosis nigricans in an adult obese population. Arch Dermatol 1992; 128:
941–4.
10. Stuart CA, Smith MM, Gilkinson CR et al. Acanthosis nigricans among
Native Americans: an indicator of high diabetes risk. Am J Public Health
1994; 84:1839–42.
11. Barbieri RL. Hyperandrogenism, insulin resistance and acanthosis nigricans.
10 years of progress. J Reprod Med 1994; 39: 327–36.
12. Rosenstein ED, Advani S, Reitz RE, Kramer N. The prevalence of insulin
receptor antibodies in patients with systemic lupus erythematosus and
related conditions. J Clin Rheumatol 2002; 7: 371–3.
13. Akovbyan VA, Talanin NY, Arifov SS et al. Successful treatment of
acanthosis nigricans with etretinate. J Am Acad Dermatol 1994; 31: 118–20.
14. Rosenbach A, Ram R. Treatment of acanthosis nigricans of the axillae using
a long-pulsed 5-alexandrite laser. Dermatol Surg 2004; 30:1158-60.
7
9.
Signature of candidate
10
Remarks of the guide
11
Name & Designation of
(in block letters)
11.1 Guide
Recommended and forwarded.
Dr. S.B. MURUGESH M.D., D.V.D., FAMS.,
PROFESSOR AND H.O.D.,
DEPARTMENT OF DERMATOLOGY,
VENEREOLOGY AND LEPROLOGY,
J.J.M. MEDICAL COLLEGE,
DAVANGERE - 577 004.
11.2 Signature
11.3 Co-Guide (if any)
11.4 Signature
11.5 Head of the
Department
Dr. S.B. MURUGESH M.D., D.V.D., FAMS.,
PROFESSOR AND H.O.D.,
DEPARTMENT OF DERMATOLOGY,
VENEREOLOGY AND LEPROLOGY,
J.J.M. MEDICAL COLLEGE,
DAVANGERE - 577 004.
11.6 Signature
12
Remarks of the
Chairman & Principal
12.2. Signature.
8