Here are a series of comments and e-mails I received from a reader named Victor, who like many people have been seeing success from a ketogenic diet with weight loss and overall feeling better, and then the dreaded keto rash appears.
He does a good job of tracking his blood ketones and diet and details his experiences below. At one point he finds success with a chinese herbal medicine, but then discovers it was just a confounding variable, and ultimately successfully treats the rash by increasings his carbs.
Here is Victors initial comment (found on this page):
First of all… I’m really thankful for your site. I stumbled onto it a couple days ago and has just been reading and digesting as much info as I can. I got the rash last week, which was about 4 weeks into ketogenic diet. This is the first time I’m doing this, so I may not have been in ketosis from the start.
Anyway, I started at 192lbs and about 20% BF, and lost about 10lbs in that 4 weeks. It is now the fifth week, and it’s weird that the weight loss has almost completely halted. I understand that rapid weight loss in the beginning is normal, due to the water being removed, but it’s just odd that I’ve lost less than 1lb in a week. I think some of your readers also reported similar observation.
My blood ketones was 5.0 when I felt like the itch was getting a bit unbearable, which was 2 days ago. Since then, I’ve tried applying tea tree oil. Yesterday, I must have consumed enough carb that when I measured, my BK was 0.3, which means I’m out of ketosis. A weird thing that I noticed was that I felt kind of fatigue, and when I exercised, I felt low in energy.
The stagnation of weight loss and the low energy makes me think that Dr Haarfeldt may be onto something with the gluconeogenesis thing. Although, I think it’s just part of a piece of a puzzle as it wouldn’t explain why the antibiotics would work and not come back even if someone continue to stay in ketosis…
When I woke up this morning, I felt the itch was less, and the rash has subsided a little. I decided to go keto again and just have eggs, coconut oil and butter for breakfast, green beans, cheese, chicken and beef for lunch… I measured my BK after lunch and it was 1.9. I continue to apply tea tree oil, al though I’m not sure if it helps or more of a placebo effect. But the rash did get a little itchier towards the evening.
I worked out in the evening, but did not feel the same low energy I did yesterday. Afterwards, I took a protein shake, had dinner which may have had a bit of sugar in it… after which I measured, and my BK is 0.5. Right now, it’s almost 10pm, and I feel like there’s not much itch in the rash anymore.
I intend to stick with the very low carb especially during the day, and maybe relax a bit for dinner. So, I’ll report back on my progress. Might try to do this n=1 experiment as long as I can bear before I give up and go down the antibiotics route.
Meanwhile, what are your thoughts on the gluconeogenesis theory?
Keep us posted as to how your n=1 works!
One thing you can explore is a cyclic keto diet. Stay hardcore keto during the week, then eat carbs during the weekend. You may be able to find a balance between staying in ketosis the majority of the time while keeping your rash at bay.
I’m not sure about the gluconeogenesis theory. I’ve been trying to look into it more.
There’s a tumor out there called a glucagonoma that secretes a lot of the hormone glucagon, which stimulates lipolysis AND gluconeogenesis… and guess what? It causes a rash!
I thought it was onto something, but the rash is completely different and in a different distribution. So… who knows.. there may or may not be a relationship, but none that I’ve managed to detect.
His reply to my comment:
Interesting info about glucagonoma… I agree the rash definitely looked different. Anyway, I think i screwed up my lunch & dinner, tonight i measured my BK at only 0.2. But, as expected the rash seems to be going away. I’m actually pretty amazed how quickly the rash subsides due to a lower BK.
Not sure if it’s related or not, but I’ve had a mild flu-like symptoms, ie. runny nose, sore throat about the same time the rash started appearing… wondering if the rash is due to a compromised immune system… or maybe just a red herring. I’m still coughing a little at this time.
I’m probably gonna just use this place as a journal for my progress. I’ll try to get back into ketosis tomorrow… I guess I should tell the mrs. to cook my food separately to avoid contamination from the carbs.
A separate e-mail he sent me a few days later:
Anyway, just wanted to provide some updates.
So, last Wednesday, Feb 10 is the last day where I increased my carb and out of ketosis. I went back to strict low carb diet and on Friday, Feb 12, when I measured my resting BK and it was 2.1, Monday, Feb 15, 0.5, and Wed Feb 17, 0.7. The rash is pretty much gone now, except for the hyperpigmentation which is expected.
1 thing I wanted to mentioned is that based on a comment about a herb, Forsythia, by one of your reader in your original post in the other blog, I did some research into Chinese meds and found out that forsythia and locinera are normally used together for their anti-inflammatory, anti-bacterial, and anti-viral (flu) properties. Somewhere on your blog, it was mentioned that the reason antibiotics like Doxy works could be due to its anti-inflammatory properties more than its anti-bacterial properties.
Anyway, since I already had mild flu-like symptoms like I mentioned in the earlier post, I thought I could kill 2 birds with 1 stone here, and bought some Chinese meds called qin chiao from amazon.
So, I’ve been taking that since Thursday, Feb 11, and my flu symptoms did go away… and the rash hasn’t returned. I’m just going to take it until I go through the bottle… which only last a little over a week anyway.
Since the rash has subsided, I lost almost 3 lbs in a week, which have stagnated when I had the rash… still feels like there’s something to do with gluconeogenesis hypothesis.
At this point of my n=1 experiment, I have a few questions …
1) did the herbs helped kept the rash at bay? I’m not ready to run a victory lap just yet, but hopeful that’s the last I’ll see of the rash.
2) is cycling out of ketosis helping? I’ll find out if the rash comes back if I continue to stay low carb.
3) Something that may have already be debunked…
Are folks more susceptible to ketorash, if they work out too much while trying to get keto-adapted? The reason I thought about this is the recommendations that I read where folks are told to take it easy as the body try to switch fuel from carb to fat…
Could too much workout during the transition cause the hormones to go out of whack, triggers gluconeogenesis for fuel, and cause the rash as a by-product?
Anyway, I’m staying the course in keeping my carb intake as low as I can, and see how things go in the next few weeks.
Followup e-mail after another couple days:
While I’m here, might as well provide some more update.
Unfortunate news.. looks like the chinese herbs didn’t do what I hope it would… I could feel that the rash was coming back last Saturday.. at the same place where it did before, as expected. But, it did keep the flu in check, although the wife and kids were hit by it… so, if anything, the herbs might be legit in keeping the flu at bay as advertised… but, since we are not here to talk about flu… let’s move on.
Once I noticed the onset of the rash, I quickly up my carb by drinking some coconut water… probably added maybe 12-15g that day. Measured my BK at night and it was 0.2. On Sunday, I made some paleo oxtail stew, I used 4 tomatoes and a couple carrots. The stew tasted sweet to me, so, I’m assuming there’s additional carbs there.
By Monday, the rash is pretty much gone again. I didn’t measure my BK though.
So, after the rash went away the first time, it took about 10 days before the rash reappear. And as soon as I up my carbs, it’s gone again. So, maybe cycling through keto might help keep it at bay? I’ll continue will my diet until the symptoms start to reappear again.
This might not be a bad thing… allows me to “cheat” abit, although I’m not necessarily introducing grains or sugar, but having the option of eating some fruits or other “sweet” veggies once in a while would be nice.
No additional insights into the gluconogenesis hypothesis. Other than, I feel like even when I drank some coconut water, I don’t think my carb intake went above 50g, but surprised to see my BK at 0.2. SO, maybe there’s something there but at this point, I’m not even sure what to try in order to prove one way or the other.
I’ll be happy to experiment if there’s a good procedure.