The Keto Rash in 50 Koreans – The Most Comprehensive Study Yet!

PP 50 koreans 2This is a great paper with one of the largest series of keto rash cases assembled to date.  They also do a wonderful job going into the history of the rash, and is probably the most comprehensive paper available.  Let’s dive in!

Prurigo pigmentosa: Clinicopathological study and analysis of 50 cases in Korea

Published in 2012, in the Journal of Dermatology

They report that this rash was first described in Japan, in 1971 (can’t wait to look at this paper), with more than 300 cases reported at the time of this papers publication.

In this retrospective study, all subjects were diagnosed with skin biopsies, using the Boer criteria.

Subjects:

  • 36/50 were female
  • Age of disease onset ranged from 7-61 years, with a mean of 22.3 years.
  • They noticed that the rash appeared more frequently during spring and summer (31/50 patients) compared to autumn and winter
  • 27/50 of the patients had previous history of recurrence

Symptoms:

  • 48/50 patients reported itchiness, with 22 of these reporting severe itching that interrupted their sleep
  • The rash was symmetrically distributed in 46 patients
  • The rash was most commonly distributed over the back and chest.
  • 21 patients had the rash on their neck
  • 5 had the rash on their extremities

PP 50 koreans

Rash Classification:

  • Early lesions – itching red bumps that can become confluent
  • Fully-developed lesions – red bumps, some of which contain a small amount of fluid
    • This lasts for about 1 week
  • Late lesions – darker bumps
  • Recurrent early lesions – Early lesions on top of late lesions
  • Recurrent fully-developed lesions – Fully-developed lesions on top of late lesions

Associated Conditions:

  • 2 patients had atopic dermatitis
  • 2 patients had metal allergies (1 patient had both)
  • 17 patients reported rash appearing after diet change, 8 of whom reported weight loss
    • Diet changes included:
      • Low carbohydrate diet
      • Predominant intake of a single item such as boiled eggs, sweet potato, and cucumber
    • The rash abated when all 17 patients stopped their diets
      • In 5 of these patients, the rash recurred when they restarted their diet
  • 5 patients reported the rash with mechanical irritation from bandages, clothing, body scrubbing
  • 2 patients reported emotional stress
  • 3 patients reported the rash after sweating from exercise or hot weather
  • 23 patients had no known cause
  • Blood markers for autoimmunity (ANA) were normal in the 10 patients that were measured

Ketone Measurements:

  • Blood ketones were measured in three patients and were normal
  • Urine ketones were measured in 21 patients and were positive in 7 subjects
    • 4 of these patients had history of dietary change (presumably a ketogenic-type diet)
    • The remaining three reported no change in diet

Treatment:

  • Minocycline 100-200 mg/day – 38 patients
    • Effective at inhibiting appearance of new rash but did not prevent recurrence
  • Dapsone 100 mg/day – 7 patients
  • Minocycline + Dapsone – 4 patients
    • Effective at inhibiting appearance of new rash but did not prevent recurrence
  • Doxycycline 200 mg/day –  1 patient
  • Erythromycine 500 mg/day – 1 patient
  • Antihistamines + topical corticosteroids – 6 patients
    • Less effective at inhibiting appearance of new rash
  • Oral and topical corticosteroids – 3 patients
    • Less effective at inhibiting appearance of new rash
  • No Treatment – 3 patients
    • Rash resolved spontaneously within weeks!

Anti-Inflammatory Effects of Antibiotics?

This section really caught my attention, and I think may provide some clues as to the underlying cause of the keto rash.

A variety of agents are used in the treatment of PP, the most effective of which are oral antibiotics such as minocycline, doxycycline and sulfonamides such as dapsone. Recently, minocycline has been preferred to dapsone because it has fewer side-effects and results in a longer remission.

The therapeutic effects of minocycline and doxycycline are thought to be due to their anti-inflammatory effects. These drugs inhibit mitogen-induced human lymphocyte proliferation, neutrophil migration and chemotaxis, and phospholipase A2.

Minocycline and doxycycline also inhibit the expression of cytokines and chemokines, which regulate leukocyte differentiation and activation and the local tissue inflammatory response.

Leukocyte activation and inflammation are key pathological features in PP, suggesting that these mechanisms may contribute to the therapeutic effects of minocycline and doxycycline.

The authors refer specifically to the anti-inflammatory effects of antibiotics rather than their anti-microbial effects as to why they are so effective in treating the rash.  This would suggest that finding associations with H. pylori and lyme disease are red herrings.  I guess only time will tell!

Antibiotics Did Not Prevent Rash Recurrence!!

This seems to address the question that I’ve been trying to answer ever since I first learned about the keto rash: do antibiotics make the rash go away permanently?

The answer according to this paper is a resounding NO!

There have been a few commenters in my initial post that reported using antibiotics, but unfortunately we haven’t had much followup.

If the cause of the rash were bacterial/infectious, then a course of antibiotics would theoretically eradicate the infection, which should cause the rash to go away permanently.

However, if the cause of the rash is from some sort of underlying inflammation (from what, we still don’t know), and this inflammation responds to the anti-inflammatory effects of the antibiotics, it would make sense that the rash would recur because the underlying cause of the inflammation was never actually addressed!

Ketones Causing Inflammation?

It’s interesting to see that in their discussion they refer to a study that showed:

… ketone bodies may also remain around the blood vessels and cause perivascular inflammation…

The idea that ketone bodies can actually CAUSE inflammation is very interesting and is something I’ll definitely have to look into further, especially since everything in the paleo and low carb community describes ketones as ANTI-inflammatory.

If you’re someone who ended up getting a biopsy and wanted to have the pathologist re-examine your results, make sure you refer them to this paper!  It does an amazing job describing the pathologic/microscopic findings of all the stages of prurigo pigmentosa and may help give them some direction.

Do Nothing?

In the three patients that had no treatment, the rash simply went away after a few weeks!

Unfortunately in my case, I waited it out for almost 8 weeks and the rash stayed with me… which was starting to gross out the BJJ Cavewife.  It wasn’t until I ate a ton of carbs that the rash started fading.

I actually have doubts about this issue which actually raised a few questions that the paper never addressed:

  • Were any of these 3 patients on low carb diets?
  • Did any of them have positive ketones?
  • Since ‘stopping their diet’ wasn’t considered a treatment, these 3 may simply have been in the group that was eating low-carb, who then stopped their diet which we know will effectively treat the rash

In any case, I’d be interested to see if waiting it out has worked for anyone else out there!

Connect With Others

More posts are also trickling in on the Keto Rash Facebook Community, so feel free to chime in over there. If you don’t have a Facebook account, you can try posting in the Keto Rash Forums.

Support This Site

Keeping this site running takes quite a bit of time, so if you've found this site helpful, please consider making a small donation. Anything will help, even a cup of coffee!

4 Comments

  1. Zane

    I commented earlier on reddit about the keto rash and kept checking this site hoping you’d post this article – so thanks a lot! I started eating fruit for the last week and my rash has faded from most parts of my body. I’m really curious about the topic of inflammation that you brought up. I’m a believer in the keto diet and the many benefits it brings, but it leads me to wonder if the rash is a sign that my body is missing some essential nutrients (carbs?) or something bad (internally) is going on and that the rash is a sign of that.

    The only reason I do keto is because it keeps my skin clear of acne. My skin breaks out and is extremely sensitive to high-glycemic foods, or really anything that spikes insulin. I’ve noticed lots of people can eat shit all day and their skin is fine, so I think my skin is just overly sensitive to hormones and inflammation. I just keep wondering if the keto diet is in fact producing unwanted inflammation and my skin is showing it.

  2. Zane

    I commented earlier on reddit about the keto rash and kept checking this site hoping you’d post this article – so thanks a lot! I started eating fruit for the last week and my rash has faded from most parts of my body. I’m really curious about the topic of inflammation that you brought up. I’m a believer in the keto diet and the many benefits it brings, but it leads me to wonder if the rash is a sign that my body is missing some essential nutrients (carbs?) or something bad (internally) is going on and that the rash is a sign of that.

    The only reason I do keto is because it keeps my skin clear of acne. My skin breaks out and is extremely sensitive to high-glycemic foods, or really anything that spikes insulin. I’ve noticed lots of people can eat shit all day and their skin is fine, so I think my skin is just overly sensitive to hormones and inflammation. I just keep wondering if the keto diet is in fact producing unwanted inflammation and my skin is showing it.

    I’ve been thinking of doing what you tried and going for a few months on the keto diet to see if it goes away on its own. It’s just that I don’t want it to be a failed experiment and then have to suffer with my whole body being covered in red bumps after 2 months.

    1. bjjcaveman@gmail.com (Post author)

      Ya… the gross thing is that as illustrated in this paper, the rash goes through different stages… normal red bumps.. then vesicles (fluid filled bumps) then a bit of scabbing with darker bumps… then new red bumps appear on top of older bumps mixed with vesicles and scabs.

      The longer you have it the longer the rash becomes hyperpigmented… and the longer it takes for the hyperpigmentation to go away. In my experience the hyperpigmentation does go away completely… eventually.. but I’ve noticed that it takes longer to resolve… the longer I allow the underlying rash to hang around.

      The BJJ Cavewife was not a fan… and I applaud her for sticking with me as I experimented with it.

  3. Denise

    Waiting it out did not work for me. It went away when I ate A TON of carbs, not fruits but really heavy carbs like cake and potatoes. After week or so of heavy carbs I reduced them and ate light again and immediately keto rash is back. I think my body has adapted and I’m constantly in keytosis. I will keep eating tons of carbs for 30 days like Matt Stone talks about and try to get back to normal. Will keep in touch and thanks for the site.

Comments are closed.