Acanthosis nigricans classically presents with symmetric hyperpigmented velvet-textured flexural and intertriginous plaques often occurring in patients with underlying insulin resistance. Involvement of the lips and oral mucosa is rare and may be suggestive of malignant acanthosis nigricans, which is considered a paraneoplastic syndrome associated with an underlying malignancy, most commonly gastrointestinal or lung cancer.1 Malignant acanthosis nigricans has a more rapid onset, characterized by ridged, velvet-like plaques involving the palms.

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