Introduction

Acanthosis nigricans (AN) is a common dermatologic condition associated with insulin resistance and is characterized by hyperpigmentation and hyperkeratosis, primarily affecting the neck, axillae, and groin (Eggiman & Feldman, 2024). AN is a significant clinical marker of insulin resistance and T2DM risk, affecting up to 90% of children with T2DM (Choudhary et al., 2023). The rising prevalence of childhood obesity has contributed to increased insulin resistance and T2DM among pediatric populations, making AD an important early warning sign for clinicians (Oranika et al., 2023). Early detection of AN provides an invaluable opportunity for timely intervention to prevent progression to diabetes and related metabolic disorders. However, children with AN are often under-assessed and go untreated because the dark brown to black, velvety skin patches may be mistaken for poor hygiene, dirt, or other dermatoses such as terra firma-forme dermatosis (Pollock et al., 2022). Clinicians and parents must not only be prepared to recognize AN in school-aged children but also invest in strengthening early identification, documentation, and referral pathways when this clinical marker is observed. Enhancing school-based awareness now can help ensure that children with possible insulin resistance are connected to timely evaluation, education, and follow-up, particularly those who may have limited access to routine pediatric care or preventive health services. To better support school-aged student health and reduce future metabolic risk, expanding school-based screening awareness and referral processes is critical, both as a preventive strategy and as a tool for addressing gaps in early detection of insulin resistance and T2DM risk. This commentary aims to examine the clinical significance of AN in school-aged children, explore its relationship to insulin resistance and T2DM risk, and advocate for strengthened awareness, screening, and referral practices among school-based and healthcare clinicians.

The Impact of Acanthosis Nigricans on Children

I started examining this issue during my doctoral project focused on acanthosis nigricans in school-aged children, with an emphasis on educating parents about its prevalence and the prevention of insulin resistance (Whitmyer, 2018). This is an important topic because of the increasing number of children I am seeing who have obesity or who have been newly diagnosed with T2DM in school settings. Nealy 21% or one in five U.S. children experience obesity (CDC, 2026), placing many school-aged children for increased risk with insulin resistance, AN, and progression toward T2DM. In addition, T2DM has more than doubled over the past two decades, rising from 9.0 per 100,000 in 2002-2003 to 17.9 per 100,000 by 2017-2018 (CDC, 2026). Beyond metabolic risk, childhood obesity can affect physical activity, self-esteem, school participation, and long-term health, making early recognition and referral an important opportunity to support the whole child. The visible skin changes from AN may increase their risk for teasing, bullying, embarrassment, and social withdrawal, particularly when the skin condition is misunderstood as “poor hygiene” or “dirty skin.” These experiences can negatively affect self-esteem, peer relationships, school engagement, and parents’ willingness to seek help, underscoring the need for sensitive, stigma-free assessment and education. Teachers and school-based health professionals are often well positioned to notice visible skin changes consistent with AN and to support timely, respectful referral for further evaluation of insulin resistance and T2DM risk. Because students may not routinely access preventive care, school-based recognition can serve as an important bridge between observation, parent education, pediatric care follow-up, and earlier intervention. Early recognition also has important health equity implications for at-risk pediatric populations. National data show higher childhood obesity prevalence among Hispanic children and non-Hispanic Black children, with prevalence also increasing as family income decreases (CDC, 2026); therefore, school-based awareness and referral pathways may help reduce missed opportunities for children who experience greater barriers to preventive healthcare access.

Strategies to Improve Early Identification and Referral

Early identification of acanthosis nigricans (AN) facilitates timely screening for diabetes and the initiation of interventions. Diagnostic approaches include visual examinations for AN, assessment of body mass index (BMI), and laboratory tests such as fasting glucose, hemoglobin A1c (HbA1c), and oral glucose tolerance tests. Management strategies encompass lifestyle modifications, weight management, and pharmacological interventions, with metformin often considered first-line therapy. Lessons learned from implementing evidence-informed practices and strategies include:

  • Increasing awareness by school nurses and teachers on recognizing the darkened, velvety skin changes commonly associated with AN, particularly on the neck, axillae, and other skin folds.

  • Schools should establish clear procedures for referring children with suspected AN to a primary care provider or pediatric clinician for further evaluation.

  • Parent and caregiver communication should explain AN as a possible clinical marker of insulin resistance without blame, shame, stigma, or negative assumptions on hygiene.

  • For parents and caregivers, simple health-literate resources can explain the relationship among AN, insulin resistance, obesity, and T2DM risk.

  • Education and awareness demonstrate a clear need for increased education among healthcare clinicians on the significance of AN. Understanding its correlation with insulin resistance can improve diagnosis rates and enable timely interventions.

  • Recognizing AN as a significant clinical marker of insulin resistance underscores the need for healthcare clinicians to incorporate routine skin examinations into assessments of at-risk pediatric populations. Early identification of AN enables preventive strategies to reduce T2DM risk and sequela.

  • A holistic approach to management is worth considering. Managing T2DM in children is complex and requires a multidisciplinary approach that incorporates lifestyle modifications, dietary changes, and potentially pharmacological treatments such as metformin. Tailoring strategies to individual patients, especially among diverse ethnic and economically disadvantaged groups with higher prevalence rates, is imperative.

Success of Children Taking Metformin

Documented outcomes among school-aged children treated with metformin for insulin resistance and T2DM support its role as an important therapeutic intervention (Alfaraidi & Samaan, 2023). For example, clinical studies indicate that metformin can lead to significant improvements in insulin sensitivity and glycemic control. Children treated with metformin have shown some reductions in BMI, fasting glucose levels, and HbA1c values. Conversely, some studies have found that metformin may be less effective in children than in adults, highlighting the need for close monitoring to evaluate treatment response and ongoing efficacy (National Institutes of Health, 2026). Long-term metformin use in children with insulin resistance may also support overall improved insulin sensitivity, while potentially reducing progression toward T2DM when combined with lifestyle modification and ongoing clinical monitoring (Alfaraidi & Samaan, 2023). Early intervention with metformin may not only help regulate blood sugar levels but also help prevent the long-term complications associated with T2DM, making it a worthwhile consideration in management plans for children with AN and insulin resistance. For example, success stories often reflect improved energy levels, weight stabilization, and overall health, reinforcing the importance of early and appropriate intervention. In summary, integrating the lessons learned into practice can help enhance clinical outcomes for children affected by AN and insulin resistance, ultimately leading to better management of T2DM.

Personal Reflections on Acanthosis Nigricans

My work on AN has deepened my understanding that subtle physical findings can be important warning signs of broader health concerns. I now view AN not only as a skin condition but also as a common clinical marker of insulin resistance and T2DM in children. This topic is especially meaningful to me, because I have seen many school-aged children with signs of insulin resistance who go unnoticed or missed by others. It underscores the importance of early detection, timely screening, family education, and multidisciplinary care. Nurses play a key role in recognizing AN, educating families in a supportive nonjudgmental manner, and advocating for appropriate follow-up. Moving forward, I am committed to applying this knowledge to support earlier intervention, improve screening practices, and promote better long-term health outcomes for children at risk of T2DM. Clinicians, families, and teachers each play an essential role in recognizing visible signs of AN, supporting timely referral, and encouraging follow-up care that addresses insulin resistance before more serious metabolic complications develop. I am also committed to getting the word out to clinicians, families, and teachers about their essential role in recognizing these visible signs of AN, supporting timely referral, and encouraging follow-up care to address insulin resistance before more serious metabolic complications develop.

Conclusion

In conclusion, exploring AN as a clinical marker for insulin resistance in children has deepened understanding of its implications for T2DM. As childhood obesity and metabolic risk continue to affect school-aged children, early recognition of AN provides clinicians, school-based health professionals, teachers, and families with an opportunity to intervene before more serious complications develop. Improving awareness, screening practices, and referral pathways can help ensure that children with AN receive timely evaluation, appropriate laboratory testing, health education, and evidence-informed management. This is especially important for children who may face barriers to preventive care, including those from underserved communities and families with limited access to healthcare resources. While some providers may be hesitant to recognize AN as a vital indicator, increasing education and communication within the medical community can help address these concerns. A proactive and collaborative approach among healthcare providers, communities, schools, and families can support earlier identification of AN, reduce stigma, and improve long-term health outcomes for children at risk. The positive outcomes observed among students initiated on metformin further highlight the importance of early recognition and proactive management.

Acknowledgements

I would like to acknowledge and thank Dr. George Peraza-Smith and Dr. Lisa Reyes for their guidance and support.