Ly et al.
HCA Healthcare Journal of Medicine (2021) 2:2
https://doi.org/10.36518/2689-0216.1149
Case Report
Erythema ab igne: Toasted Skin Syndrome
Author affiliations are listed
Vincent Ly, DO,1 James E. Vandruff, DO,1 Julia Fashner, MD, MPH, FAAFP1 at the end of this article.
Abstract
Correspondence to:
Introduction Julia Fashner, MD, MPH,
Erythema ab igne is a benign skin condition caused by long-term exposure to infrared radi- FAAFP
ation and/or heat. Erythema ab igne begins as a mild erythema over the previously exposed
University of Central
areas and develops into an erythematous reticulated hyperpigmentation with scaling and
telangiectasias. Florida College of
Medicine/HCA GME
Clinical Findings Consortium
A 55-year-old female presented to the primary care clinic with concerns due to the develop- Ocala Regional Medical
ment of a rash on her lower back in the previous 1 to 2 weeks. She had a history of chronic
Center Family Medicine
back pain and was using conservative treatment for pain management, including daily use
of a heating pad for 15 minutes every hour. Residency
1431 SW First Ave.
Interventions Blitzer Building, Suite 7
There is no definitive therapy for erythema ab igne. Elimination of the heat source may Ocala, FL 34471
reverse the erythema and hyperpigmentation.
(Julia.fashner@
hcahealthcare.com)
Outcome
The patient was counseled regarding the importance of limiting and/or discontinuing the
use of the heating pad to facilitate resolution of the rash. The patient did not return to the
clinic and resolution of the rash was not confirmed.
Keywords
erythema ab igne; erythema; erythema/pathology; hot temperature/adverse effects;
hyperpigmentation/etiology
Introduction tological condition is based on clinical findings
Erythema ab igne (erə’THēmə ab ignē) is a and supporting history.
benign skin condition caused by long-term
exposure to infrared radiation or heat. In Latin, Historically, erythema ab igne has been asso-
it translates to “redness by fire”.1,2 This condition ciated with occupations that experience pro-
has many other names such as hitze melanoses longed exposure to heat, such as bakers and
(German for “melanosis induced by heat”), metal foundry workers.4 It was also common
ephelis ignealis, heat-induced circumscribed in individuals with chronic exposures to fires
dermal melanosis, livedo reticularis e calore and prior to the development of central heating.4
toasted skin syndrome.2 The temperature required to produce the
rash is lower than what is required to cause a
Erythema ab igne begins as a mild erythema burn, typically between 43 and 47°C or 107.6
over the previously heat-exposed areas and de- and 116.6°F.5,6 With the increasing use of por-
velops into an erythematous, reticulated hyper- table electronic technologies, there have been
pigmentation with scaling and telangiectasias reported cases associated with exposure to
present over the same area.3 Generally, the rash heated car seats, heating pads, space heaters,
is reported to be asymptomatic and often is hot laptops or hot water bottles.5
an incidental finding. Diagnosis of this derma-
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HCA Healthcare Journal of Medicine
Figure 1. Examination of the rash demonstrated diffuse erythema with hyperpigmented reticulat-
ed telangiectasia.
Case Presentation rash. The patient did not return to the clinic
This case pertains to a 55-year-old female with and resolution of the rash was not confirmed.
a history of chronic back pain, fibromyalgia and Additionally, due to the lack of follow-up to ob-
morbid obesity. The pain had been located in tain a biopsy if necessary, a definitive diagnosis
the middle to lower back and did not radiate of erythema ab igne was not possible.
but was increasing in intensity and frequen-
cy. The patient lived a sedentary lifestyle but Treatment
reported less mobility secondary to her wors- There is no definitive therapy for erythema ab
ening back pain. The patient was status-post igne. Elimination of the heat source may re-
thoracolumbar nerve block injection 4 months verse the erythema and hyperpigmentation.5,7
prior and had plans for a repeat injection. For cases that are chronic or improve minimally
after elimination of the heat source, the use
She presented to the primary care clinic with of topical steroids or tretinoin and hydroqui-
concerns due to the development of a rash on none may reduce the discoloration.7 Five-flu-
her lower back over the previous 1 to 2 weeks. orouracil has been shown to help destroy the
(Figure 1) The patient expressed worry that the atypical cells that make up the reticulated rash
rash would prevent her from receiving a second of erythema ab igne.7 Mesoglycan with topical
injection for back pain symptom management. flavonoids has also been shown to reduce the
She denied recent trauma or osteopathic/ discoloration.8-10
chiropractic manipulation. She noted she was
seated or lying in bed for 20 to 22 hours a day.
The patient was using conservative treatment
Discussion
A review of the literature found the majority of
for pain management, including a heating pad
cases were reported in middle-aged to elderly
on her back. She reported attempting to keep
adults suffering from chronic musculoskeletal
the heating pad applied for only 15 minutes but
pain, with lesions appearing after application of
often was applying the heating pad every hour
hot water bottles or heating pads.1-17 In younger
throughout the day. Besides cosmetic con-
adult and pediatric populations, the incidence
cerns, the rash was asymptomatic.
of erythema ab igne was more frequently asso-
ciated with the use of heat-generating porta-
The patient was counseled regarding the im-
ble electronic devices such as laptops or space
portance of limiting or discontinuing the use of
heaters.1,11
the heating pad to facilitate resolution of the
98
Ly et al. (2021) 2:2. https://doi.org/10.36518/2689-0216.1149
The pathophysiology of the rash has not been ab igne since cold exposure causes the dis-
fully established, but some studies indicate coloration as opposed to warm exposure in
that thermal radiation exposure induces dam- erythema ab igne.9 Cutis marmorata telangiec-
age to the superficial blood vessels, which leads tasia is characterized by persistent reticulated
to epidermal vascular dilation.11 The hyper- blanching erythema with possible atrophy. This
pigmentation, which can occur in a reticular condition is congenital and can be associated
distribution, is thought to be due to deposition with vascular malformation, limb asymmetry,
of hemosiderin.4,12,13 One study that obtained neurologic or ocular abnormalities. One distin-
biopsies for pathological evaluation proposed guishing feature includes occasional ulceration
radiant (infrared) energy enters the dermis development along the lines of atrophy. Ad-
and activates lysosomes.2 The enzymes be- ditionally, due to its congenital nature, it can
come free to diffuse into the tissue and digest be accompanied by other anomalies including
susceptible substances such as collagens and syndactyly, port-wine stain, clubfoot, etc.9,13
elastic fibers. These condense with chronic
exposure and produce elastosis or degenerative Although erythema ab igne is largely a benign
changes with increased deposition of elastin, incidental finding, there are reports of asso-
resulting in the classic characteristic rash of ciated insidious pathologies. There have been
erythema ab igne.2 Other theories attribute the reported cases of erythema ab igne developing
rash to repeated exposures to infrared radia- cutaneous malignancies such as squamous cell
tion. The repeated exposures lead to a marked carcinoma or Merkel cell carcinoma.5,17 In other
erythema, hyperpigmentation and occasional studies, erythema ab igne was a dermatolog-
epidermal atrophy.14 ical finding in patients with underlying malig-
nancies such as colorectal, pancreatic, gastric,
Histologically, erythema ab igne resembles renal, breast and/or hematologic malignancies.3
actinic keratosis with the epidermis showing It has been suggested that the underlying
atypical cells. There is also associated accumu- malignancy may serve as the source of chronic
lation of dermal elastic tissue, which is an early pain that leads patients to use heating devices
sign of both UV radiation and heat-induced that will lead to development of the rash.17
skin damage.14
Conclusion
Erythema ab igne can resemble other skin Heat is often recommended by physicians as
conditions, including livedo reticularis, livedo conservative treatment for musculoskeletal or
racemose, cutis mamorata and cutis marmora- chronic pain. It is important to consider erythe-
ta telanglectasia.9,15 Livedo reticularis is charac- ma ab igne as a potential complication when
terized by a mottled reticular pattern and often recommending this relatively benign treatment
has purple discoloration. These findings are due or as a potential diagnosis in patients with
to impaired blood flow and occurs after expo- an unexplained rash who are utilizing heating
sure to cold temperature. These symptoms will modalities for pain control. With increasing
resolve as the tissue rewarms.9 Like erythema use of portable electronics, practitioners need
ab igne, livedo racemose is also characterized to revisit safe practice guidelines of heat-
by a violaceous net-like rash, but the rash is generating technologies. Differentiating this
more widespread as opposed to being limited benign condition from similar looking rashes
to a specific exposed area. Additionally, the will ultimately prevent exposing patients to
shape is irregular, and this skin condition is also unnecessary testing, costly treatment and
commonly associated with pathological condi- unnecessary referrals to specialists. Due to the
tions.16 risk of underlying malignancies associated with
erythema ab igne, it is important the condition
Cutis marmorata is the physiological form of is properly diagnosed and followed in the pri-
livedo reticularis and is a normal response of mary care setting.
the body.9 This form is often seen in infants
and resolves with age. Livedo reticularis may
be indicative of underlying pathology, includ- Conflicts of Interest
ing lupus, vasculitis, toxins, etc. These types of The authors declare they have no conflicts of
pathology are differentiated from erythema interest.
99
HCA Healthcare Journal of Medicine
The authors are employees of Ocala Regional spective multicenter study. J Cosmet Derma-
Medical Center, a hospital affiliated with the tol. 2020;19(7):1774-1779. https://doi.org/10.1111/
journal’s publisher. jocd.13210
11. Riahi R, Cohen PR. What Caused This Hyper-
This research was supported (in whole or in pigmented Reticulated Rash On This Man’s
Back? The Dermatologist. 2013;21(1).
part) by HCA Healthcare and/or an
12. Cavallari V, Cicciarello R, Torre V, et al.
HCA Healthcare affiliated entity. The views Chronic heat-induced skin lesions (erythe-
expressed in this publication represent those of ma ab Igne): ultrastructural studies. Ultra-
the author(s) and do not necessarily represent struct Pathol. 2001;25(2):93-97. https://doi.
the official views of HCA Healthcare or any of org/10.1080/01913120117614
its affiliated entities. 13. Morrison M, Cotton J, LaFond A. Reticulated
erythematous patch on teenager’s foot. J Fam
Pract. 2014;63(9):537-539.
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1. University of Central Florida College of dition new again. CMAJ. 2000;162(1):77-78.
Medicine/HCA GME Consortium, Ocala 15. Kienast AK, Hoeger PH. Cutis marmorata telan-
Regional Medical Center Family Medicine giectatica congenita: a prospective study of 27
Residency, Ocala, FL cases and review of the literature with pro-
posal of diagnostic criteria. Clin Exp Dermatol.
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