Ketorash: An underdiagnosed entity

Ketoacidosis-Induced Prurigo Pigmentosa is a rare, inflammatory disease characterized by pruritic, erythematous papules with a reticulate pattern on the torso and neck. It affects predominantly young adult Asian women with risk factors for metabolic ketosis, such as Diabetes Mellitus, anorexia nervosa, bariatric surgery and ketogenic diet.
A 26-year-old female being treated for refractory focal frontal and generalized epilepsy with ketogenic diet for four months was consulted due to a three-month-long dermatosis which started in the anterior and posterior cervical region and progressed towards the dorsal midline area. Skin lesions were papular and erythematous, often merging with a vaguely reticulated pattern. These lesions were highly pruriginous and worsened during periods ofhigher ketonemia.  
Histological examination of a cutaneous biopsy sample was compatible with Ketorash. The patient suspended ketogenic diet and was medicated with topical erythromycin, with full resolution of the lesions and no recurrences after 8 months.