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 A_1c 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.