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Thickened Velvety Plaques in a 75-Year-Old Woman
The Diagnosis: Tripe Palms and Acanthosis Nigricans
A shave biopsy specimen from the left palm showed slight epidermal hyperplasia with substantial papillomatosis and compact orthokeratosis. The complete blood cell count, thyrotropin level, uric acid level, liver function tests, mammogram, Papanicolaou test, and chest radiograph were unremarkable. A basic metabolic panel showed mildly elevated blood glucose at 111 mg/dL (reference range, 70-99 mg/dL) and hemoglobin A1c at 6.3% (reference range, <6.0%). Full-body computed tomography, endoscopy, and colonoscopy initially were normal. One year later after presenting with tripe palms, the patient had a bowel obstruction secondary to omental carcinomatosis from a primary ovarian tumor.
The term tripe in tripe palms refers to the resemblance to the edible lining of the bovine foregut. It originated in 1963 from a patient's own description of the rugose velvety texture of the palms.1 In the literature, tripe palms also is called acanthosis palmaris, acanthosis nigricans of the palms, palmar hyperkeratosis, palmar keratoderma, and pachydermatoglyphy. It is a rare cutaneous finding. Tripe palms is associated with other cutaneous paraneoplastic syndromes such as malignant acanthosis nigricans (72% of cases) and Leser-Trélat sign (10% of cases). It affects more men than women (63% vs 37%) and is almost exclusively seen in adults (median age, 62 years).1
The clinical appearance of tripe palms includes hypertrophy of the palms and often the soles with papillations producing a velvety or honeycomb appearance. In addition, the dermatoglyphics are pronounced. The histologic findings typically show hyperkeratosis and acanthosis. Other features that can be seen include dermal mucinosis and increased mast cells in the dermis. To differentiate tripe palms from other keratodermas, substantial papillations can be seen with less diffuse hyperkeratosis.1
Tripe palms has been associated with an underlying malignancy in more than 90% of published cases. In two-thirds of cases, tripe palms either appears before or concurrent with the diagnosis of cancer.2 It is rarely reported as an idiopathic finding or associated with nonneoplastic disorders. Malignancies most commonly associated are adenocarcinomas, especially of the stomach (27%) and lungs (22%). Other neoplasms, such as in our patient, include those of the genitourinary tract and breast. In a patient with tripe palms in the absence of acanthosis nigricans, the most common neoplasm is of the lung, especially when clubbing of the nails also is present.2 Thus, after a diagnosis of tripe palms is established, a thorough investigation for an underlying malignancy is the next most important step to direct specific therapy.
1. Cohen PR, Grossman ME, Silvers DN, et al. Tripe palms and cancer. Clin Dermatol. 1993;11:165-173.
2. Moore RL, Devere TS. Epidermal manifestations of internal malignancy. Dermatol Clin. 2008;26:17-29.
The Diagnosis: Tripe Palms and Acanthosis Nigricans
A shave biopsy specimen from the left palm showed slight epidermal hyperplasia with substantial papillomatosis and compact orthokeratosis. The complete blood cell count, thyrotropin level, uric acid level, liver function tests, mammogram, Papanicolaou test, and chest radiograph were unremarkable. A basic metabolic panel showed mildly elevated blood glucose at 111 mg/dL (reference range, 70-99 mg/dL) and hemoglobin A1c at 6.3% (reference range, <6.0%). Full-body computed tomography, endoscopy, and colonoscopy initially were normal. One year later after presenting with tripe palms, the patient had a bowel obstruction secondary to omental carcinomatosis from a primary ovarian tumor.
The term tripe in tripe palms refers to the resemblance to the edible lining of the bovine foregut. It originated in 1963 from a patient's own description of the rugose velvety texture of the palms.1 In the literature, tripe palms also is called acanthosis palmaris, acanthosis nigricans of the palms, palmar hyperkeratosis, palmar keratoderma, and pachydermatoglyphy. It is a rare cutaneous finding. Tripe palms is associated with other cutaneous paraneoplastic syndromes such as malignant acanthosis nigricans (72% of cases) and Leser-Trélat sign (10% of cases). It affects more men than women (63% vs 37%) and is almost exclusively seen in adults (median age, 62 years).1
The clinical appearance of tripe palms includes hypertrophy of the palms and often the soles with papillations producing a velvety or honeycomb appearance. In addition, the dermatoglyphics are pronounced. The histologic findings typically show hyperkeratosis and acanthosis. Other features that can be seen include dermal mucinosis and increased mast cells in the dermis. To differentiate tripe palms from other keratodermas, substantial papillations can be seen with less diffuse hyperkeratosis.1
Tripe palms has been associated with an underlying malignancy in more than 90% of published cases. In two-thirds of cases, tripe palms either appears before or concurrent with the diagnosis of cancer.2 It is rarely reported as an idiopathic finding or associated with nonneoplastic disorders. Malignancies most commonly associated are adenocarcinomas, especially of the stomach (27%) and lungs (22%). Other neoplasms, such as in our patient, include those of the genitourinary tract and breast. In a patient with tripe palms in the absence of acanthosis nigricans, the most common neoplasm is of the lung, especially when clubbing of the nails also is present.2 Thus, after a diagnosis of tripe palms is established, a thorough investigation for an underlying malignancy is the next most important step to direct specific therapy.
The Diagnosis: Tripe Palms and Acanthosis Nigricans
A shave biopsy specimen from the left palm showed slight epidermal hyperplasia with substantial papillomatosis and compact orthokeratosis. The complete blood cell count, thyrotropin level, uric acid level, liver function tests, mammogram, Papanicolaou test, and chest radiograph were unremarkable. A basic metabolic panel showed mildly elevated blood glucose at 111 mg/dL (reference range, 70-99 mg/dL) and hemoglobin A1c at 6.3% (reference range, <6.0%). Full-body computed tomography, endoscopy, and colonoscopy initially were normal. One year later after presenting with tripe palms, the patient had a bowel obstruction secondary to omental carcinomatosis from a primary ovarian tumor.
The term tripe in tripe palms refers to the resemblance to the edible lining of the bovine foregut. It originated in 1963 from a patient's own description of the rugose velvety texture of the palms.1 In the literature, tripe palms also is called acanthosis palmaris, acanthosis nigricans of the palms, palmar hyperkeratosis, palmar keratoderma, and pachydermatoglyphy. It is a rare cutaneous finding. Tripe palms is associated with other cutaneous paraneoplastic syndromes such as malignant acanthosis nigricans (72% of cases) and Leser-Trélat sign (10% of cases). It affects more men than women (63% vs 37%) and is almost exclusively seen in adults (median age, 62 years).1
The clinical appearance of tripe palms includes hypertrophy of the palms and often the soles with papillations producing a velvety or honeycomb appearance. In addition, the dermatoglyphics are pronounced. The histologic findings typically show hyperkeratosis and acanthosis. Other features that can be seen include dermal mucinosis and increased mast cells in the dermis. To differentiate tripe palms from other keratodermas, substantial papillations can be seen with less diffuse hyperkeratosis.1
Tripe palms has been associated with an underlying malignancy in more than 90% of published cases. In two-thirds of cases, tripe palms either appears before or concurrent with the diagnosis of cancer.2 It is rarely reported as an idiopathic finding or associated with nonneoplastic disorders. Malignancies most commonly associated are adenocarcinomas, especially of the stomach (27%) and lungs (22%). Other neoplasms, such as in our patient, include those of the genitourinary tract and breast. In a patient with tripe palms in the absence of acanthosis nigricans, the most common neoplasm is of the lung, especially when clubbing of the nails also is present.2 Thus, after a diagnosis of tripe palms is established, a thorough investigation for an underlying malignancy is the next most important step to direct specific therapy.
1. Cohen PR, Grossman ME, Silvers DN, et al. Tripe palms and cancer. Clin Dermatol. 1993;11:165-173.
2. Moore RL, Devere TS. Epidermal manifestations of internal malignancy. Dermatol Clin. 2008;26:17-29.
1. Cohen PR, Grossman ME, Silvers DN, et al. Tripe palms and cancer. Clin Dermatol. 1993;11:165-173.
2. Moore RL, Devere TS. Epidermal manifestations of internal malignancy. Dermatol Clin. 2008;26:17-29.
A 75-year-old woman presented with progressive, velvety, thick skin involving the bilateral axillae, inner thighs, palms, and buccal mucosa. She also reported weight loss of approximately 25 pounds over the last 12 months. Her medical history was notable for metabolic syndrome, allergic rhinitis, and colon polyps. She denied a family history of malignancy. On physical examination, she was a healthy-appearing overweight woman. The palmar surface of the bilateral hands was thickened and velvety with exaggerated dermatoglyphics. She had similarly thickened, velvety, gray-brown plaques on the bilateral axillae and proximal aspects of the inner thighs. The buccal mucosa had a thickened rugose texture.
