Background: Acanthosis nigricans (AN) is a dermatological condition characterised by hyperpigmented, velvety, thickened skin, primarily affecting intertriginous areas such as the neck, axillae, and groin. It is strongly associated with insulin resistance, obesity, metabolic syndrome, and, in rare cases, malignancies. Various treatment modalities, including chemical peels, fractional CO2 laser, and microneedling, have been explored to improve the cosmetic appearance of affected skin. However, no definitive consensus on treatment exists. Objective: This systematic review aims to evaluate and compare the efficacy of chemical peels like Trichloroacetic acid (TCA), Glycolic acid (GA), Retinoic acid (RA), etc, with or without physical modalities such as fractional CO2 laser, and microneedling in managing AN, assessing their clinical outcomes, safety profiles, and long-term effectiveness. Methods: A systematic search of electronic databases was conducted to identify randomised controlled trials (RCTs), cohort studies, and comparative clinical studies evaluating the efficacy of chemical peels in AN treatment. Studies reporting objective clinical improvements, patient-reported outcomes, and adverse effects were included. The primary outcome measure was improved pigmentation and skin texture, which was assessed using validated scoring systems such as the Acanthosis Nigricans Area and Severity Index (ANASI). Results: A total of 8 eligible studies were included. TCA (15-20%) peels demonstrated significant improvement in pigmentation compared to glycolic acid (35-70%), though higher concentrations increased the risk of post-inflammatory hyperpigmentation (PIH). Microneedling, particularly when combined with TCA peels, enhanced treatment outcomes by improving agent penetration and collagen remodelling. Conclusion: Chemical peels offer varying degrees of efficacy in the treatment of AN. TCA peels remain a cost-effective first-line option, while physical modalities such as fractional CO2 laser offer superior long-term benefits for thicker lesions. Microneedling enhances the effects of peels, making combination therapies a promising approach. Future studies should focus on standardising treatment protocols, assessing long-term outcomes, and exploring newer treatment combinations to optimise AN management.