Prurigo Pigmentosa – A Few More Thoughts

StethoscopeOne of my readers, Doctor Timothe, was kind enough to write a very thoughtful response and analysis of my first post on prurigo pigmentosa, and while I was in the middle of typing a response in the comments section, I thought it’d probably be more helpful to write it as a full post.

I am a surgical ER Doctor thats been following you for a while, but I am no Dermotologist. I have been in ketosis for almost 2 years, and i maintain High cardio exercise, and have never had such a problem, nor hear of it.

You didnt post many pictures, so i cant really diagnose, or guess to much. But let me take a few swings, I know you do Martial arts and you use a Gi ( is it clean? how often do you clean it? and partners you spar with may of has a rash you got from them?)

Carbs may of been the treatment, But the question is why would flooding your self with sugars be the answer? I dont think it is, I think the inflamatory properties of the ketosis foods vrs the carb rich foods is the answer.

Could you of been deffecent in any vitamins or minerals? you are eating a normal ketosis diet right? not VLCD ?

Would also like to add this my be directly related in some ways to overdosing with some Vitamins and minerals, specifically I mean heavy metal poisoning, Lead, Nickel, Copper, arsenic.

You did not mention being sick or stomach cramps. Intestinal problems would likely be the first sign on those kinds of overdoses, But we are all human and are not thinking in such a manner and will pass it off.

Now Heavy metals stay in the body for a long time, and you ate carbs and found relief. I theorize that, in ketosis you my of had concentrated abouts of Heavy metals, But with carbs your body’s water composition increased greatly, thus kinda diffusing the toxicity levels.

In addition, you stopped eating carbs, body water concentration went down, rash came back with the increased concentration of metals. Then went away again, with carbs.

The toxcity levels would stay till your body metabolized the metals, or excreeted, or due to biological halflife…

– Dr. Timothe

Thank you for such a thorough response!  Here are some of my initial thoughts:

1.  It’s great to see that you have not experienced this rash.  It’s not a very common rash and not much is known about it still at this point.  I was able to do a comprehensive literature search going back to 1978 in pubmed and found only 300-400 cases ever described, in all of the literature.  So it’s probably safe to say that most people aren’t going to get this (looks like I’m one of the unlucky ones).

2. Pictures – Unfortunately I didn’t take more pictures of my own body as this was happening.  Once I was diagnosed by the dermatologist, I kind of let things go.  I thought, ‘Pytiriasis Rosea is a well described entity in the literature, and this guy probably knows what he’s talking about so I’ll just do what he recommends.”

In retrospect I should have taken more pictures to document this phenomenon.  I didn’t want to go too overboard using pictures from the literature because I didn’t want to raise any copyright issues.  Most of the journals I read required an account to access, and since I’m affiliated with an academic institution I have access to them.  Here’s a link to other pictures of this rash from the internets.  Mine looked liked a milder form of some of these.

3. Inflammatory nature of ketosis foods – This wouldn’t quite explain the pathogenesis in all the patients that developed the rash in diabetic induced ketosis/ketoacidosis, in which the rash resolved with simple administration of insulin.  My diet consisted of coconut oil, grass-fed butter, bacon, cruciferous vegetables, organic omega 3 eggs, beef, tomatoes, avocados, chicken, and dark chocolate to name a few.  I can’t imagine these things to be inflammatory.

4. Vitamin/mineral deficiency – Not sure.  I don’t think this is the case because I was able to make the rash go away almost immediately after reintroduction of carbs.  My understanding is vitamin deficiency (such as scurvy) actually take a while to develop.  I actually thought about scurvy since I know it can present with a rash… so I took some vitamin C during this time, which didn’t really help.  Not sure about other minerals since I’ve never really measured mineral levels in my body…

5. No other symptoms such as GI issues… just the rash.. which was only mildly itchy.  Hot water seemed to exacerbate the itchiness.

6. Heavy metals – I’m dubious to the idea as to water concentration ‘unmasking’ the presence of heavy metal toxicity.  When I do a rigorous work out, BJJ/Crossfit/Basketball, I go pretty intensely and can be very bad about rehydrating.  This would in theory leave me to be hypovolemic and water depleted, which should unmask any underlying heavy metal toxicity I have, but this rash has never occurred before in any of those situations.  Since I’ve never measured my levels of heavy metals, it’s something I’ll consider doing during my next blood test.

7. Martial Arts Hygiene – I have to admit, ring worm was one of the first thoughts that crossed my mind.  I had it once a few years ago, and ever since I’ve become meticulous with my hygiene.  When I train in BJJ, I always wear a long sleeve rash guard and compression leggings under my GI, no matter how hot it is.  The only parts of my body that are exposed are my head and neck, my hands, and my feet.  None of these places were affected by the rash.. only my trunk which is covered by the rash guard and GI, with no skin to skin contact.  I also wash my gear after every training session.  The instructor of my BJJ academy makes sure to clean the mats at least 3 times a day.  I felt better after the dermatologist specifically said he didn’t think it was ring-worm… which is a disease that they see and treat all the time.  All of these factors made me pretty confident that it wasn’t ring worm.

8. It’s not to say that any of these aren’t possibilities.  The point is that not enough is known about prurigo pigmentosa and it’s causes.  I just wanted people to be aware of this and provide an easy to read resource.  There are definitely other rashes that look like this which can also confuse the issue.  If you have a rash, it’s still probably a good idea to get it checked out by your doctor.

23 Responses to Prurigo Pigmentosa – A Few More Thoughts

  1. jj says:

    Just hypothetically, if you’re wearing a full body rash guard that would trap the sweat on the surface of your skin for a period of time… changes in the composition of your sweat in ketosis vs. not in ketosis could possibly affect this. That being said… good on you for the rash guard, and your academy with the cleaning… ringworm is one thing, but I’d hate to see anyone catch MRSA, it’s been known to happen in contact sports.

  2. BillA says:


    I’ve had this rash in my armpits for about 2 months now which is about how long I’ve been in ketosis. I finally went to the dermatologist today and she decided to treat it as psoriasis and prescribed 1% hydrocortisone. I’ll get her to prescribe doxy based on your research.

    FYI, my diet is practically identical to yours; coconut oil, MCT, coffee, grass-fed butter, bacon, cruciferous vegetables, organic omega 3 eggs, beef, tomatoes, avocados, 90% dark chocolate, nuts, cheese, salads with olive oil, pork, etc… Similar supplements as well. I’m getting great results other than the rash.

    I wonder if there might be a food or supplement interaction.

    Also, I’ve read where H. Pylori and Borrelia Sp. (Lyme pathogens) have also been associated with this rash.

    Any thoughts on these two potential causes?


    • BJJ Caveman says:

      Thanks for stopping by. I don’t think its a food interaction or supplement thing because with my current experiment…. Keeping food and supplements essentially stable, my rash comes back and goes away solely based on whether or not I’m in ketosis.

      I will write more about this on my follow up post.

      I’m not sure about borrelia or Lyme as a cause… There isn’t much in the scientific literature about that so I can’t say…

      Keep us updated on how the doxy works.

  3. Andrew says:

    Have u found any solution to the rash? I am also experiencing a rash/hives while on ketosis and the doctor has no clue what it is.

    • BJJ Caveman says:

      Does the rash go away when you fall out of ketosis? Try upping your carbs for 3-5 days and see what happens with the rash. If like me, the rash disappears then you know its keto-rash. If not then it’s something else.

      If you conclude that it’s keto rash, as of now you have a few options that some people have found works for them.

      1. If you want to remain in ketosis, then take antibiotics… doxycycine or minocycline for 10-14 days. This is what is reported in the literature and what some readers have found is successful. We have at least one person reporting that this has allowed them to remain in ketosis, rash free for 3 months.

      2. Increase your carbs to the point where you are completely out of ketosis… just quit trying keto. This has also been shown to work in the literature, and is something I’ve found works for me.

      3. Increase your carbs slighlty to find that magical sweet spot where you can stay in ketosis AND keep the rash at bay. This has worked for at least one reader.

      4. Do cyclic keto, where you stay in keto throughout the week and have 1-2 carb up days. This has worked somewhat well for me during my carb nite experiment.

      Hope this helps!

  4. Matt says:

    I recently finished the 10 day preparation phase for carbbackloading, probably the first time in my life where I really went into ketosis. The rash/hives appeared about 8 days in and I had no idea what it was. My physician prescribed a topical steroid cream (I don’t want to have to take an oral steroid) and diagnosed it as hives, not really knowing what it was. Since then, I’ve been staying ultra low carb during the day, eating coconut oil first thing in the morning, coffee, eggs with vegetables and a fatty meat, then salad and chicken during my ULC portion of the day. I’ve been backloading with about 300-400 g of Carbs in the evenings after my workouts and I’m happy with the results I’m seeing so far (I really dropped a few body fat %’s during the 10 day prep phase).

    Unfortunately, the rash hasn’t gone away at all yet. I ideally want to do carb nite because I’m at about 10% body fat and want to get down to about 7%) but I know backloading is better to rectify this rash. I believe I’m correct in saying that while backloading 5-6 times a week, my body’s glycogen stores are being filled and my body isn’t relying on ketones anymore. I’m wondering if this rash is every going to go away or am I just going have to settle with not utilizing either of these diets and eating carbs all day long. It’s been really frustrating as I’m sure you guys know.

    • Andrew says:

      I’m on day 2 of the oral steroid prescribed by my doc and seeing little to no improvement with the rash. It’s mainly on under my arms, lower back, and upper abdomen… all the places I mainly sweat when working out. I also saw no improvement when getting out of ketosis (carb nites) so I’m hoping this is just some sort of contact dermatitis. I first started noticing it after a I started bikram yoga. I’ve been on the keto diet now for about a month. I’ll check back in a week and let you know how the oral steroids worked. My next step is going to be acupuncture.

      • BJJ Caveman says:

        When you get out of ketosis, how long are you out of it? Sometimes for me it took at least 2-3 days of being out of ketosis to elicit improvement.

    • BJJ Caveman says:

      Strange that the rash doesn’t abate with the 300-400 gm of Carbs. How hard are you working out? IF you’re doing super high intensity stuff and or super long endurance stuff, you may be burning through whatever glycogen you have!

      I would try keeping carbs up for 3-4 days straight to see if that helps the rash. In my case it is pretty effective. IF that doesn’t help, then it might be something else…

      you could always try the antibiotics, doxycycline or minocycline, since that has been effective in the literature and with some of the commenters here.

  5. Adam says:

    This was really excellent timing, I’m glad this is a current thread and not one from 5 years ago like a lot of the paleo articles I read. with that said, sorry if you’ve addressed some of this, I haven’t been through your entire site yet, but I wanted to comment before I forget.

    For the last 4-5 years I’ve struggled with a very similar dry/itchy rash, as well as hives. After using several creams both steroid and non steroid, I decided to stop going to dermatologists. This is when I started experimenting with my diet, and eventually how I discovered Paleo.

    Slowly reducing carbs (I suspect grains, and not carbs were the culprit) seemed to improve the dry/itchy rash (PP?), but the hives never went away. That is, until I tried eggs. I can now notice a very clear relationship between when I eat eggs, and when I get hives. Haven’t had an allergy test, but at this point I don’t even think it’s necessary.

    If you haven’t tried it, I suggest anyone with strange symptoms like this try removing eggs (or do a full 30-day autoimmune protocol, to be more thorough). I was strictly paleo/ketogenic for the past 2 months, and it wasn’t until a few beer and egg related incidents that my rash/hives returned.

    I’m curious, during your Carbnite experiment, what exactly were you eating on carb nite? I know you said trying for rice/potatoes/sweet potatoes, but how close to that did you stick? I’m thinking about trying carbnite, but working out a plan still.

    • BJJ Caveman says:

      Some people have tried experimenting with autoimmune protocol. At least in my case, I’m not that convinced since it’s so reproducible with my carb intake and degree of ketosis.

      With my carb nite experiment, first few weeks were pretty good wtih the rice and potatoes.. and as I got more positive feedback and more confident, things went off the deep end and I ate everything I wanted pretty much… gluten and all! Shame on me. Feels good to get that off my chest!!! j/k

  6. ddhirsh says:


    I am a 60 year old healthy woman – taking no medications – a little overweight and I find Fat Fasting – The Keckwick Diet – Ketogenic diet outstanding for kickstarting a weight loss campaign. However, I always get “the rash” as described by you and others. It was perplexing the fist time it happened about three weeks in until I saw that others have experienced the same thing: on the trunk, back, and in my case also inner thighs. It is dismaying to think the medical community doesn’t have a clue. Much literature extolls the virtues of a ketogenic diet and intermittent fasting, etc – buy the rash is a little scary making one think that perhaps the diet isn’t so healthy – e.g. why is this happening? Toxins being released in body perhaps – like the doctor said – heavy metals in a body with a lower amount of H20 retention? At any rate. rash goes away after I add back carbs. Also, another interesting thing is that the rash starts almost immediately now when I enter ketosis. This time, four days in – it is there but not too intense yet. I wan’t to stick it out at least ten days.

    • BJJ Caveman says:

      Keep us updated! I’ve found that the longer I do ketosis, the emptier my glycogen levels, the easier it is to get back into it, the faster the rash appears.

      But if I stay out of ketosis for a while and all my glycogen is topped off, the rash doesn’t appear as quickly…

      I really feel that it has a relationship with glycogen levels also…

  7. Robert M says:


    Since I started doing cardio to prepare for sprint triathlon I got the rash with a vengeance.

    I have been reading all over the Internet including this site.

    I have learned that anorexic ppl can get the same rash.

    Since I have been eating lchf for over 3 years I didn’t exercise especially much. Last autumn I combined lchf and 16 h fasting every day. That’s when the rash can at first. But just a couple on my right arm (didn’t realize until now what it was) but now with a lot of cardio training the rash really went crazy.

    After starting to be less strict, adding safe starches with a low glycemic index after I exercise the rash is fading.

    Although I haven’t given up the benefits of a lchf lifestyle, that you can still have without borderline ketosis. I can also add that I have been stabile in weight since 2 years ago when I lost almost 20 kg with lchf.

    Since I don’t need to lose anymore weight I can afford to not live super strict.

    Hope this can give some hope to someone struggling and don’t wanna give up lchf lifestyle.

    • BJJ Caveman says:

      Thanks for your comment! What you mention really supports my current thinking that it is somehow related to glycogen levels.

      Eating lchf will deplete your glycogen levels, but not all the way since your body becomes more efficient at using it. But once you throw in exercise on top of already low levels of glycogen, the glycogen stores really get to the bottom of the barrel, and that seems to be when the rash is most severe, at least in my case!

      • Robert M says:

        I also consulted an author of a book called a sweeter blood, Ann Fernholm. She told me that you can get vitamin deficiency on a very strict ketosis with a lot of fat. This is observed when treatment of epileptic children.

        All very interesting.

        A lchf in my style contains a lot of fat cream and there is some carbs to keep me above the threshold in general. Although I switched to mayo during the time the rash spread.

        Thanks for the feedback.

  8. jerry says:

    Im not sure if i had the same rash but i noticed after 6months on lchf diet i started to get a rash on my hands and arms.

    After some research i discovered it may be caused by an imbalance of copper and zinc.
    I take supplements of both, after stopping copper supplementation but keeping everything else the same the rash has started to go away.

    • BJJ Caveman says:

      From what I’ve read, it would be unusual for prurigo pigmentosa to appear on the hands and arms… but who knows!

      Have you been testing your blood ketones?

      • jerry says:

        Not yet, need to by a monitor. It may have just been a different rash caused by my copper-zinc imbalance and nothing to do with attempting to stay in ketosis.
        I only took copper as a supplement as i could not convince the Mrs to cook me liver.
        I would love to get most of my nutrients from food.

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