Some call it keto acne, keto hives, keto itch, or the scientific name, “prurigo pigmentosa”. But whatever you call it…
It’s not good.
Keto rash is typically defined by a symmetrical rash covering the neck, back and shoulders. But in rare cases, it can appear elsewhere on the body. It’s an unsightly rash that can seemingly last forever. And for those that suffer from keto rash, the widespread and constant itchiness can be an extremely annoying problem.
However, the biggest problem with keto rash is not the rash itself, but the lack of information surrounding the condition. The truth about keto rash has been so obscured by misinformation - that sufferers are left with no real answers as to what causes it, and how to treat it.
Lucky for you, we’re here to help.
In this article, you’ll learn exactly why keto rash develops - and what you can do to treat it. But before we do that, let’s take some time to clear up all the confusion.
Keto Rash: Myths and Theories
There’s a ton of confusion around the topic of keto rash. And that’s because - when it comes to prurigo pigmentosa - almost every other health and nutrition blog gets it wrong.
If you do a quick google search on keto rash right now, you’ll find a laughably long list of causes and cures - each one more ridiculous than then next. But you can skip the search and save your time. Here’s what keto rash isn’t…
- It’s not a skin or hygiene problem;
- It’s not the result of ketones “leaking” through the skin;
- It’s not because ketosis has negatively altered your gut bacteria;
- It’s not a keto-induced inflammatory response; and most importantly...
- It’s NOT because your body can’t handle nutritional ketosis.
The cause of keto rash is actually quite simple. So let’s get to it.
How to Spot Keto Rash: Signs and Symptoms
If you know anything about dermatology, you know that skin issues are confusing!
There’s acne, hives, itchiness, rashes, bumps, bruises and everything in between. And even after careful analysis of an issue, it can still be impossible to tell exactly what’s wrong.
If you’re struggling to understand if your rash is a keto rash, look no further - because we’re here to help. Below is an outline of the stages of keto rash and how to identify if you’re dealing with prurigo pigmentosa.
Early-Stage Keto Rash
In this stage, you’ll likely notice light pink, raised skin lesions around your neck, back, and shoulders. Here’s what they typically look like...
Fully Developed Keto Rash
In this stage, you’ll have a pronounced rash that covers the same area where the early rash developed. You’ll find numerous skin lesions (called papules) - some of which contain liquid or puss. If your rash looks anything like the below, it’s time to take keto rash seriously.
Resolving Keto Rash
Once you start treating your keto rash (keep reading to learn how), you’ll enter this phase of resolving lesions. The rash will recede, and the papules will crust and appear darker in color.
Late-Stage Keto Rash
As your rash heals and recedes, the area that was once covered in pink papules will show a pattern of darker pigmented spots. This is called “reticulated hyperpigmentation", and may last for a long time after the rash is resolved. Which means, it’s even more important to get out in front of keto rash, and resolve it before it can reach a more severe stage. And the first step to avoiding keto rash is understanding exactly what keto rash is!
What is Keto Rash?
Keto rash should actually be called “protein deficiency rash” (or, PDR for the acronym crowd). And that’s because keto rash is not caused by your diet being too ketogenic; it happens when your diet is too low in protein.
Simple as that.
When people transition to a ketogenic diet, they’re often overly concerned with keeping dietary fat as high as possible. Many people even push their fat intake to over 80% or more of their total calories. And believe me...I get it.
Seeing positive results from a high fat diet can make you think, “if high fat is good, higher fat must be better”. I thought the same thing.
But if you focus too much on increasing the fat percentage of your diet, you can end up with a real deficiency in dietary protein. And that’s when you may start to develop an itchy and unsightly rash.
We don’t know exactly why a protein deficiency leads to keto rash. But we do know that it has something to do with the combination of protein deficiency AND high levels of circulating ketones. That’s why, for some people, a keto rash can even appear after extended periods of fasting! When protein intake drops and ketone levels rise, keto rash can become a serious problem.
But here’s the good news…
We do know enough about keto rash to propose an effective solution. And this isn’t just a theoretical solution. We’ve tested this ourselves and seen positive outcomes in countless others.
If you want to treat keto rash, you need to increase your protein.
How to Treat Keto Rash
Step one is simple. You’ll want to stop any of the unnecessary keto rash treatments found on other blogs. You can find a list of these treatments - along with the reasons they don’t work - below...
Antibiotics: Doxycycline, etc.
An antibiotic like doxycycline is an effective treatment for bacterial infections - including those that occur on the skin. But keto rash is not a bacterial infection - so there’s no reason to use doxycycline or any other antibiotics. As well, there can be serious side effects from oral antibiotics (like doxycycline) that make them especially not worth the risk.
Just like antibiotics, these creams are usually targeted at bacterial infections. Unless you find a cream that can transdermally deliver significant amounts of dietary protein, then save your money and skip the skin creams.
Just like keto rash, the term “essential oil” is a confusing misnomer. And that’s because essential oils like lavender and rosemary extracts are not “essential” at all.
If your goal is to have a nice-smelling house or apartment, then go ahead and grab some essential oils. But if your goal is treating keto rash, you can ignore essential oils.
Apple Cider Vinegar
Apple cider vinegar is an acidic compound. And thus, it certainly has antimicrobial properties. However, keto rash is not caused by skin bacteria - so apple cider vinegar is a misguided treatment plan
Bile salts like cholic, deoxycholic, chenodeoxycholic and lithocholic acid are often touted as a supplement to look into if you’re dealing with keto rash. If you want to use these supplements, we won’t stop you. But we wouldn’t expect any of them to magically cure your keto rash.
Change your Clothes
Many keto rash treatments focus on the idea that ketones contained in sweat can dry out your skin and encourage bacteria growth. Thus, the recommended solution is to wear lighter clothing - especially in hotter climates.
While there is some evidence that suggests acetone may encourage bacterial growth (link), the idea that acetone excreted through the skin can cause a severe rash is a major stretch. Furthermore, if this was the cause of keto rash, we’d expect the incidence rate for keto rash to be far greater than it currently is for people in nutritional ketosis.
So...if you want to wear lighter clothing, feel free. But don’t expect your keto rash to disappear after a quick wardrobe change.
Pictured: A fashionable summer look that won't treat your keto rash.
Upgrade Your Hygiene
No matter what you read on the topic of keto rash, you’ll inevitably encounter advice to improve your personal hygiene. This includes advice to take more showers, wash your body with soap and water more regularly, and even keep your fingernails short.
While improving your personal hygiene is always recommended for all humans, we don’t suspect you’ll find much benefit for keto rash. And if you’re not trimming your fingernails already, keto rash isn’t the reason you need to start.
Eat More Carbs
Here’s the truth...eating more carbs will work to treat keto rash. But if your goal is to stay in ketosis, then eating more carbs is NOT a viable treatment at all.
If you simply stop eating keto and embrace a Standard American Diet (SAD), any instance of keto rash will likely disappear. But over time, you’ll have bigger problems - as the consequences of this diet may wreak havoc on your health.
As well, the reason keto rash disappears with increased carb intake is most likely due to the protein-sparing effect of carbs. Meaning, that because more carbohydrates are present to be used for energy, some protein is spared from fuel metabolism and able to be used for other important functions.
So...while increasing carbs may seem like a tempting strategy, there is an equally easy solution that will allow you to maintain ketosis AND treat that annoying keto rash.
And here it is…
Increase your protein.
If you want to treat keto rash, you need to increase your protein. Consuming 1 gram per pound of body weight per day is a great place to start. But 1.5 g/lb will clear up your keto rash even faster.
I personally used this strategy to treat my own experience with prurigo pigmentosa - and I’ve cycled protein up and down to prevent keto rash (and support optimal health) ever since. As I learned, there’s more to optimal nutrition than increasing fat as high as possible. And if your macronutrients are out of sync, your body will let you know.
Here’s the truth. If you’re a hardcore keto head that measures blood ketones on a daily basis, you’ll likely see your average blood ketone value drop.
Don’t get discouraged.
Ketone envy is real (more on that in a future blog). I know how it feels to want to get that ketone reading higher at all costs. But we must remember, a high ketone reading is not the only thing that matters when it comes to health and nutrition.
That feeling when you catch him jealously eyeing your ketone reading...
Maintaining protein at 1-1.5g/lb will allow you to avoid troublesome reactions (like keto rash) while still enjoying the benefits of nutritional ketosis. And once your rash is completely gone, you can still achieve impressively high ketone values on certain days. You just need to cycle protein higher on a regular basis in order to prevent keto rash from ever developing again.
Implementing a higher protein diet for 2-3 days each week is highly recommended. And it’s best if these days are non-consecutive. That way, you can maintain ketosis (and impress your friends with your sky-high ketone readings) without risking the development of an extremely annoying rash.
If you keep an active training or fitness regimen, you’ll want to be even more conscious of your protein intake. More active individuals require more protein - and this fact will become painfully obvious if you suppress your protein too low and develop an unsightly keto rash.
Cure and prevent Keto Rash. For Good!
Keto rash is a real problem. But lucky for all of us, there’s a simple solution. And it’s not antibiotics, lighter clothing, soapier soap, or any of the other remedies you’ve read about.
You can still enjoy the lifelong benefits of a ketogenic diet without developing keto rash. You just need to be smart and maintain adequate dietary protein.
If that sounds complicated, don’t worry. We’re here to help! Email us by clicking here or leave a comment below!