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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 4  |  Page : 335-340  

A study of body mass index, waist circumference, body fat percentage, blood sugar levels, and lipid profile in patients of facial acanthosis Nigricans


1 Department of Dermatology, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Radiodiagnosis & Imaging, Armed Forces Medical College, Pune, Maharashtra, India
3 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission26-Aug-2019
Date of Decision07-Oct-2019
Date of Acceptance07-Oct-2019
Date of Web Publication20-Jul-2020

Correspondence Address:
Saikat Bhattacharjee
Departments of Radiodiagnosis, Armed Forces Medical College, Pune - 411 040, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_244_19

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  Abstract 


Introduction: Facial acanthosis nigricans (FAN) is a term used synonymously and interchangeably with metabolic melanosis and metabolic melasma. FAN is described as brown-to-black macular pigmentation with blurred ill-defined margins, commonly found on the forehead and zygomatic and malar areas with varying degrees of textural changes ranging from mild roughness to frank verrucous appearance of the affected areas. Aims and Objective: (i) The aims and objectives were to study the clinical patterns of FAN; (ii) to determine the prevalence of obesity, dyslipidemia, and blood sugar levels in patients of FAN; and (iii) to determine the association of body fat percentage (BFP) with sex, body mass index (BMI), serum triglycerides, and waist circumference (WC). Materials and Methods: This was a prospective descriptive study. One-hundred patients of FAN were included in the study that carried out over a period of 1 year. The BMI and WC of the included patients were used as parameters of obesity. BFP, lipid profile, and blood sugar levels were measured. Data were also obtained on the basis of history and clinical examination. Results: The patterns of facial pigmentation seen included the forehead and zygomatic (43%), zygomatic and malar (16%), involving the forehead (32%), and diffuse darkening of the face (9%). Overall periorbital and perioral darkening were seen in 22% of the patients, while acanthosis nigricans of other sites was found in 65% of the patients. Eighty-eight patients (88%) reported exposure to sunlight of >2 h. Twenty-one percentage of patients were overweight and 61% obese on basis of the BMI, WC was high in 62% of the patients, and BFP was high in 74% of the patients. High-density lipoprotein (HDL) levels were low in 50% of the cases, while hypertriglyceridemia was found in 38% of the cases. However, no derangement of blood sugar levels was found in any patient. A significant statistical association was found between high BFP with male sex (P = 0.004), high BMI (P = 0.0002), high WC (P < 0.001), and low serum HDL levels (P = 0.039). Conclusion: We document an increased prevalence of obesity, deranged lipid profile, and high BFP in patients presenting with FAN, and it should be considered a cutaneous marker of obesity. Furthermore, a simple tool such as BFP can be used to screen patients of FAN for obesity.

Keywords: Body fat percentage, facial acanthosis nigricans, obesity


How to cite this article:
Sinha P, Bhatnagar A, Bhattacharjee S, Tripathy DM, Yadav AK. A study of body mass index, waist circumference, body fat percentage, blood sugar levels, and lipid profile in patients of facial acanthosis Nigricans. Med J DY Patil Vidyapeeth 2020;13:335-40

How to cite this URL:
Sinha P, Bhatnagar A, Bhattacharjee S, Tripathy DM, Yadav AK. A study of body mass index, waist circumference, body fat percentage, blood sugar levels, and lipid profile in patients of facial acanthosis Nigricans. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Aug 9];13:335-40. Available from: http://www.mjdrdypv.org/text.asp?2020/13/4/335/290171




  Introduction Top


Facial acanthosis nigricans (FAN) also commonly known as metabolic melanosis or metabolic melasma presents with dryness, roughness, and brown-to-black pigmentation of the facial skin, commonly involving the zygomatic and malar areas. The pigmentation is later accompanied by changes such as hypertrophy and increased skin markings along with a velvety slightly coarse texture. Few studies done by Verma et al. and Panda et al. have documented the increased prevalence of obesity and insulin resistance in such patients.[1],[2] However, the number of such studies is still few.[1],[2] We undertook a prospective descriptive study to study the clinical patterns of FAN as well as to determine the prevalence of obesity, dyslipidemia, and high blood sugar levels in 100 patients of FAN. The body mass index (BMI), waist circumference (WC), and body fat percentage (BFP) measurement were used as markers for obesity. This measurement of BFP is a novel thing not done earlier in patients of acanthosis nigricans (AN).

Aims and objectives

The aims and objectives were to (i) study the clinical patterns of FAN; (ii) to determine the prevalence of obesity, dyslipidemia, and deranged blood sugar levels in patients of FAN; and (iii) to determine the association of BFP with sex, BMI, serum triglycerides, and WC in these patients.

Inclusion criteria

All consecutive, willing, and consenting patients presenting to the outpatient department (OPD) of dermatology with clinical features of FAN described as brown-to-black macular pigmentation with ill-defined margins, with varying degrees of textural changes with many having similar lesions over the neck, axilla, groin, and other flexures were included in the study.

Exclusion criteria

Patients having non-FAN-related causes for facial pigmentation such as melasma, pigmented contact dermatitis, lichen planus pigmentosus, erythema dyschromicum perstans, riehl's melanosis, pigmentary demarcation lines, postinflammatory pigmentation, and drug-induced pigmentation were excluded from the study.

Study design

This was a prospective descriptive study conducted at a dermatology outpatient clinic of a tertiary care hospital. The study was conducted over a period of 1 year.


  Materials and Methods Top


One-hundred consecutive consenting patients of FAN who fulfilled the inclusion criteria were included in the study. Ethical clearance was obtained from the institute. Each participant in the study was subjected to detailed history taking with regard to the onset, duration, and progress of the pigmentation, and associated aggravating factors such as excessive exposure to sunlight, atopy, friction, occupational exposure to chemicals, cosmetics, and medications were applied onto the face. Age, sex, occupation, drug history, family history of AN, diabetes, hypertension, and dyslipidemia were also noted. Menstrual and reproductive history was noted in females.

The dermatological examination was done in detail in each patient with regard to the site of pigmentation and color, and textural changes were noted. The presence of AN at other body parts and the presence of skin tags and acne were also noted. Each patient underwent tests for fasting and postprandial blood sugar levels and lipid profile.

BMI was calculated by weight in kilograms divided by the square of body height in meters (kg/m2). The consensus statement for diagnosis and treatment recommendations for obesity and metabolic syndrome in Asian Indians was used to classify the patients.[3] The patients were classified on the basis of their BMI as normal: 18.0–22.9 kg/m2, overweight: 23–24.9 kg/m2, obese >25 kg/m2, and morbidly obese >30 kg/m2.

WC was measured on standing using a nonstretchable flexible tape in a horizontal position, just above the iliac crest, at the end of normal expiration with the individual standing erect. As per the consensus statement in the study by Misra et al., the risk of developing Type 2 diabetes, hypertension, and cardiovascular disease is higher in men with WC ≥36″ and in females with WC ≥32″.[3]

Dysglycemia was defined as fasting blood sugar level >100 mg/dl and postprandial >140 mg/dl.

Lipid profile was measured, and a level of triglycerides ≥150 mg/dl and high-density lipoprotein (HDL) levels of <40 mg/dl in males and <50 mg/dl in females were considered to be deranged.

BFP was measured using bioelectrical impedance analysis (BIA) method with the help of Bodystat 1500 machine. All measurements were taken during morning hours(0830–1200), and the participants were well hydrated and had not undertaken any vigorous physical activity in the preceding 12 h before the measurement. The procedure was carried out according to the manufacturer's instructions. According to the American Council on Exercise, average fat percentage in males is around 18%–24%, while in females it is 25%–31%.[4] Furthermore, taking into consideration a study by Gallagher et al., we took the cut-off of >20% in males and >30% in females to denote high levels of BFP.[5]

All the data were stored and analyzed. Data were summarized by calculating mean, standard deviation, and proportion. The SPSS software for the statistical analysis was used (Stata Corp LP, TX, USA).


  Results Top


One hundred patients were found to have FAN over a period of 1 year of the study duration. The mean age of the patients with FAN was 32.6 ± 11.56 years. The youngest patient was 15 years, whereas the oldest one was 66 years. The male-to-female ratio was 15.6:1 (94 males and 6 females). The main findings are summarized in [Table 1].
Table 1: Baseline characteristics of the study population (n=100)

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Eighty-eight patients (88%) reported exposure to sunlight of >2 h. Twenty-nine patients gave a positive family history of diabetes in the family (29%), while hypertension in the family was present in four cases (4%).

The most common sites of FAN were the forehead and zygomatic region (43 patients, 43%), only the forehead region in 32/100 (32%), 16/100 (16%) had pigmentation on the zygomatic and malar region, while 9% of the patients had generalized facial pigmentation [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. The overall periocular and perioral involvement was seen in 22% of the patients. The skin in the affected areas was raised, rough, and rugose.
Figure 1: Facial acanthosis nigricans as a linear band over the forehead

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Figure 2: Facial acanthosis nigricans involving the forehead and zygomatic areas; also seen are multiple acrochordons

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Figure 3: Facial acanthosis nigricans involving the forehead, zygomatic, and periocular areas; also seen are multiple acrochordons

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Figure 4: Facial acanthosis nigricans involving the entire face

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Figure 5: Facial acanthosis nigricans seen over the zygomatic and malar areas

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Apart from the face, AN was found in 65 patients (65%) over the neck, axillae, and bilateral inguinal regions. The most common texture of the skin was noted as dry and rough. Associated acrochordons were present in 10% and acne in 6% of the patients.

BMI levels revealed 21/100 (21%) to be overweight, 51 (51%) obese, and 10 (10%) morbidly obese. WC was high in 62/100 (62%) patients.

Blood sugar, both fasting and postprandial, was normal in all the individuals. Lipid profile revealed low HDL in 50/100 (50%) and hypertriglyceridemia was found in 38/100 (38%).

BFP was found high in males in 74 cases (74%), and all the females had a BFP within the normal range of <30%. A significant statistical association was found between high BFP with male sex (P = 0.004), high BMI (P = 0.0002), high WC (P < 0.001), and low serum HDL levels (P = 0.039) [Table 2] and [Table 3].
Table 2: Association of body fat percentage with sex, body mass index, and waist circumference

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Table 3: Association of body fat percentage with serum high-density lipoprotein levels, serum triglycerides, and serum cholesterol

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Overall, our results showed a significant association of male sex, high BMI, high WC measurements, and high BFP to FAN.


  Discussion Top


AN manifests as brownish-black and velvety thickening of the skin affecting the neck, axillae, inguinal, and inframammary folds. FAN, also called metabolic melanosis or metabolic melasma, is a variant of AN affecting predominantly the frontal, zygomatic, and malar areas of the face which can manifest as mild xerosis to verrucous thickening and hyperpigmentation.[1] The intricate association of AN with obesity has been studied extensively, but studies on FAN are few.[6],[7] Studies done by Verma et al. and Panda et al. have found a high probability of occurrence of FAN in patients with abnormal oral glucose tolerance test, increased waist–hip ratio, and increased BMI.[1],[2]

We attempted to find the different clinical patterns of FAN and its association with three clinical entities in the form of obesity, dyslipidemia, and dysglycemia and to measure them using five parameters including BMI, WC, BFP, blood sugar levels, and triglyceride levels. BFP is a novel parameter which was measured with the BIA method using Quadscan 4000 analyzer from Bodystat 1500. Few studies have associated BFP with obesity and ours is the first study to use it as a tool to measure obesity in patients of FAN.[8]

A total of 100 patients attending the dermatology OPD were included in the study out, of which the age group ranged from 15 to 66 years with a male predilection of 15.6:1. Nighty-eight percentage had bilaterally symmetrical FAN, and in 88%, the onset was in the past 4 years. The forehead and zygomatic areas had predominant involvement. Other associated cutaneous features were present in 20% of of patients which predominantly included acne (6%) and acrochordons (10%).

The most significant history elicited was that of sun exposure of more than 2 h daily. Verma et al. found 21.5% of patients who gave a history of sun exposure for >2 h/day and Panda et al. found 74.80% patients who were exposed to sunlight for >2 h a day, which is similar to our study. This raises a question regarding the role of sunlight in the etiopathogenesis of FAN. It is too early to comment on this issue, but most of the studies being done on FAN are showing significant association with the duration of sun exposure.

In our study, 82% of the patients had abnormal BMI, of which 61% were either obese or morbidly obese, which was in accordance with the study conducted by Verma et al. (74%). High WC was found in 62% of the patients. Hypertriglyceridemia and low HDL levels were found in 53% and 40% of the males, respectively, and were normal in all females taken in the study reiterating the fact that the male gender is more predisposed to FAN. Our findings were similar to the studies conducted by Sharquie and Al-Ogaily and Verma et al. except the blood sugar levels which were normal in all patients in our study.[2],[6]

According to the consensus statement provided by Misra et al., metabolic syndrome is defined as the occurrence of any three of the following criteria:[3]

  1. WC >35 inches in males and >32 inches in females
  2. High triglyceride, more than or equal to 150 mg/dl
  3. Low HDL, <40 mg/dl in males and <50 mg/dl in females
  4. High blood pressure, more than 130/85 mm of Hg
  5. High blood sugar, fasting more than 100 mg/dl.


Of the 100 patients, 90% of the patients had at least one criterion of metabolic syndrome and 36% fulfilled two criteria of metabolic syndrome. Commenting more on metabolic syndrome in the context to our study would be inappropriate due to a lack of inclusion of blood pressure measurements.

A high BFP was found in 74% of the patients. BFP is used to measure the fitness level of an individual. It is the only body measurement which directly calculates a person's relative body composition without regard to height or weight. A number of methods are available for determining the BFP, such as measurement with calipers or using BIA. We used the BIA method as it was easily available in our hospital. A significant association was found with male sex (Fisher's exact = 0.004), with BMI (Fisher's exact = 0.002), WC (Fisher's exact = 0.000), and with HDL (Fisher's exact = 0.491).


  Conclusion Top


Considering India as an epicenter of obesity and lifestyle diseases, rapid and simple tools for screening these entities are necessary. FAN is a simple visual finding that can be looked for OPDs and can be used as an important clinical finding. A comprehensive examination and biochemical workup can ensure timely remedial measures in the form of pharmacotherapy and lifestyle modifications. Weight reduction in obese patients can lead to clinical improvement. Counseling of the patient for behavioral weight management comprises diet, exercise, and behavior modification to encourage sustained lifestyle changes. Furthermore, decreasing prolonged sun exposure and the use of sunscreens is to be encouraged.

Additional parameters such as glycated hemoglobin, blood pressure, serum insulin, and low-density lipoprotein levels may further strengthen the study and should be included in further studies on FAN.

Limitations of the study

We would like to highlight some of the shortcomings of the current study. A small sample size and lack of a comparative analysis using a control group were the major limitations. Facial biopsies were not done in patients due to its invasive nature and the patients' concerns regarding a possible scar on their faces. The BIA is a low-cost method but not very accurate way to estimate BFP. However, it is simple to use and is easily available.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Panda S, Das A, Lahiri K, Chatterjee M, Padhi T, Rathi S, et al. Facial acanthosis nigricans: A morphological marker of metabolic syndrome. Indian J Dermatol 2017;62:591-7.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Verma S, Vasani R, Joshi R, Phiske M, Punjabi P, Toprani T. A descriptive study of facial acanthosis nigricans and its association with body mass index, waist circumference and insulin resistance using HOMA2 IR. Indian Dermatol Online J 2016;7:498-503.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
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. 3
    
4.
Muth ND. What are the Guidelines for Percentage of Body Fat Loss. American Council on Exercise (ACE). Ask the Expert Blog; 2009.  Back to cited text no. 4
    
5.
Gallagher D, Heymsfield SB, Heo M, Jebb SA, Murgatroyd PR, Sakamoto Y. Healthy percentage body fat ranges: An approach for developing guidelines based on body mass index. Am J Clin Nutr 2000;72:694-701.  Back to cited text no. 5
    
6.
Sharquie KE, Al-Ogaily SM. Acanthosis nigricans as a cause of facial melanosis (Clinical and histopathological study). IOSR J Dent Med Sci 2015;1:84-90.  Back to cited text no. 6
    
7.
Varthakavi PK, Waingankar A, Patel KL, Wadhwa SL, Khopkar U, Sengupta RA, et al. Acanthosis nigricans: A dermatologic marker of metabolic disease. Indian J Dermatol Venereol Leprol 2002;68:67-72.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Rodríguez G, Moreno LA, Blay MG, Blay VA, Garagorri JM, Sarría A, et al. Body composition in adolescents: Measurements and metabolic aspects. Int J Obes Relat Metab Disord 2004;28 Suppl 3:S54-8.  Back to cited text no. 8
    


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