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With the popularity of keto and low-carb diets, more and more people are successfully losing weight through them. At the same time, however, most people experience varying degrees of adverse reactions, including keto rash, which can be the most unpleasant reaction even though only a small percentage of people will develop a rash at the beginning of the keto diet.

While varying degrees of keto rash can interfere with our normal lives, it is not more dangerous to health and can be cured or even avoided. In today’s article, we’ll go into detail about why this nasty rash occurs and how to combat it.

What is the Keto Rash?

Keto rash is a relatively rare inflammatory skin condition that has a specific scientific term called pruritus pigments, also known as Nagashima’s disease. This term was originally coined by Japanese dermatologists in 1971. The keto rash presents as itchy and lesional skin with bumps that usually range in color from light pink to red to brown.

Pigmented pruritus is associated with several medical conditions, including Helicobacter pylori infection and autoimmune diseases such as dry syndrome. In addition, the condition may also occur in people with type 2 diabetes and in those who have fasted or eaten a very low-carb diet for a long time.

According to studies and many reports to date, the consumption of either very low carbohydrates or calories can lead to ketosis, which can trigger a ketosis rash in susceptible individuals.

In fact, since the 1990s, researchers have known of a link between ketosis and pruritus pigments. Another study found that women were 2.6 times more likely than men to develop the rash, especially young women between the ages of 20 and 30.

What are the Symptoms of Keto Rash?

The keto rash usually occurs on the trunk, back, neck, and armpits and is symmetrical, typically appearing within days or weeks of entering ketosis.

It looks much like eczema or dermatitis but has a distinctive reticular pattern. In the early stages of the rash, it is usually characterized by skin lesions that range in color from light pink to brown and look much like scratches. When the sores begin to fill with fluid and become infected, they develop into full-blown lesions. And at the end stage, it looks like a dark spot or freckle. This hyperpigmentation may persist long after the rash has subsided.

The following diagram shows the three stages of keto rash onset and progression.

• Figure A: Early lesion – the skin shows light pink bumps that look like scratches and are accompanied by mild itching.
• Figure B: Complete lesion – the skin surface appears as a papule or cluster of small, hard red bumps, some of which may be filled with fluid or pus. At this stage, itching usually increases but varies from person to person.
• Figure C: Late Rash – The lesion becomes brown and crusty. Affected skin is left with a light brown reticular pattern of dark patches called reticular hyperpigmentation.

The severity of the rash varies from person to person and the duration varies, from a week or two to several months. However, the last stage generally lasts longer.

Although the ketosis rash is usually confined to the front and back of the body, in some cases it spreads to the upper thighs. Very occasionally, it may appear on the forehead or extremities. Although the ketosis rash affects your appearance and can be very uncomfortable, it is not dangerous in itself.

What Causes Ketosis?

Although studies have found a link between pruritus pigments and ketosis, the underlying cause of the rash has not been determined. However, there are several potential triggers associated with ketosis that may contribute to the rash.

Excessive Fasting

In a scientific study of fasting, a ketosis rash occurred in 50% of the participants. This is likely because prolonged fasting keeps blood sugar levels low and the body enters a state of ketosis, resulting in a rash.

Very Low Carb Diets

This includes the keto diet, zero-carb diet, primal diet, Atkins diet, low-carb Mediterranean diet, etc. These diets are very low in carbohydrates and can cause blood ketone levels to rise, leading to rapid weight loss in a short period, producing, among other side effects, a ketone rash.

Ketone Bodies

During ketosis, your body will produce large amounts of ketone bodies that can cause perivascular inflammation and trigger a rash. Ketone bodies are also excreted through sweat, irritating the skin with painful itchiness, which explains why ketosis rashes often appear on the parts of the body that are most prone to sweating.

Insufficient Bile Secretion

The most common manifestation of bile deficiency is itchy skin. The main role of bile is to break down lipids. When you eat a keto diet, because the fat intake is greatly increased, the pressure on the liver and gallbladder increases and you cannot ensure that sufficient bile is released in time to digest this extra fat, causing dermatitis.

Intestinal Ecological Disorders

Many people who start a keto diet are unable to ensure a variety of foods, which may lead to an imbalance of the intestinal flora. Harmful bacteria get out of control and overpopulate, overwhelmingly outnumbering healthy bacteria, which leads to the production of toxins and inflammation, causing skin problems such as acne, rosacea, and eczema.

Toxins Irritate the Skin

Some of the toxins in your body are stored in fatty tissue and cells, and when you start a keto diet, your body will burn fat as a source of energy.

During this process, toxins previously stored in fat cells are released into the bloodstream. If your liver is not functioning well, these toxins will be excreted through sweat, which in turn explains why keto rashes tend to occur in areas where sweat accumulates.

Allergens

It’s not hard to understand that some ingredients in a keto diet can cause allergic reactions, such as seafood, eggs, etc.

Lack of Micronutrients

Lack of certain nutrients in the body may also lead to rashes.

What to Do About a Ketosis Rash?

Because the root cause of the keto rash has not been identified, the best treatment plan for it is controversial. For some people, the keto rash is a temporary problem that goes away on its own with time and adaptation to a new diet, but if you find that it’s been weeks and the rash still doesn’t get better or comes back easily, then you’re probably susceptible and need to change your diet to address it.

You can try the following 5 ways to relieve symptoms:

1. Increase the number of carbohydrates in your diet until you withdraw from ketones.

Try increasing the number of carbohydrates to 50-100g (this will take you out of ketosis) and see if your rash gets better. If the symptoms lessen, lower your carbs again and watch for the rash to reappear. If it reappears, your body may be sensitive to ketones. You can choose a milder low-carb diet instead of a keto diet, and the key is to find the optimal point of carbohydrate intake.

2. Avoid prolonged fasting

Most people use a keto diet in conjunction with light fasting to achieve the best weight loss results. If you are doing the same and have developed a rash, you can stop fasting for now and raise your daily carbohydrate intake slightly to 40-50 grams. After the rash subsides, then try to slowly extend the fasting time, but don’t fast for more than 24 hours either.

3. Identify allergens

One of the possible causes of a keto rash is a food allergy, so you can try to identify the allergen. The most common keto foods that may trigger an allergy are:

• Dairy products (e.g. cheese, full-fat yogurt)
• Eggs
• Fish (e.g. tuna, fresh fish)
• Shrimp
• Seafood (e.g. oysters, crab)
• Nuts (e.g. macadamia nuts, almonds, peanuts)

To find out if you are allergic to a certain food or not, you can do the following:

• Remove those foods that tend to cause allergies from the list of ingredients and observe them for a few weeks to see if the rash symptoms lessen.
• If there is a relief, add one of the foods to your diet again and wait 1-2 weeks.
• If the rash does not reappear or worsen, add the new food.
• If no symptoms appear, continue to add a new food every 1-2 weeks.
• If the rash reappears after introducing the new food, it is the trigger that caused your allergy.

This may be trickier, but at least you have hope of finding the allergen.

4. Trace element supplementation

To rule out any causes related to nutritional deficiencies, make sure to include as many vitamins and minerals in your diet as possible, which are generally difficult to obtain on a keto diet.

• Minerals: During the transition to a keto diet, minerals such as sodium, potassium, magnesium, and calcium, which are essential for cell function and energy, are reduced.
• Vitamins and Omega-3 fatty acids: They are necessary to regulate inflammation. Since ketosis rash is an inflammatory response, additional supplementation of these nutrients is necessary.
• Bile salts: Bile salts present in the bile help the liver to process large amounts of fat properly, so it is advisable to take extra bile salt supplements on a keto diet.

How Can I Prevent Keto Rash?

Since the underlying cause is unknown, there is no completely effective way to prevent ketosis rash. However, it is an uncommon adverse reaction, so you may not experience this trouble at all. If you’re still concerned, you can do these two things to minimize the likelihood of keto rash.

Start keto gradually

If you’ve been used to eating a high-carb, low-fat diet before, it’s best not to cut out your carbohydrate intake all at once, but to adapt to this new way of eating gradually and slowly.

You can go from eating staple foods at three meals a day and gradually reduce to eating staple foods at two meals and only protein and fat at the other. After your body has adapted, then reduce to one main meal and two meals of only protein and fat.

Eventually move to a day where the main foods are mainly healthy fats, with moderate protein, and carbohydrate sources are mainly green leafy vegetables and low-carb fruits or nuts.

Watch your skin condition

Keep an eye on what you eat and how your body reacts to them, and once a potential rash appears, boost your carbohydrate intake and confirm if this is the underlying cause.