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Reticulated Brownish Erythema on the Lower Back
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Diem-Phuong D. Dao, MD
Dirk M. Elston, MD

The Diagnosis: Erythema Ab Igne

Based on the patient's long-standing history of back pain treated with heating pads as well as the normal laboratory findings and skin examination, a diagnosis of erythema ab igne (EAI) was made.

Erythema ab igne presents as reticulated brownish erythema or hyperpigmentation on sites exposed to prolonged use of heat sources such as heating pads, laptops, and space heaters. Erythema ab igne most commonly affects the lower back, thighs, or legs1-6; however, EAI can appear on atypical sites such as the forehead and eyebrows due to newer technology (eg, virtual reality headsets).7 The level of heat required for EAI to occur is below the threshold for thermal burns (<45 °C [113 °F]).1 Erythema ab igne can occur at any age, and woman are more commonly affected than men.8 The pathophysiology currently is unknown; however, recurrent and prolonged heat exposure may damage superficial vessels. As a result, hemosiderin accumulates in the skin, and hyperpigmentation subsequently occurs.9

The diagnosis of EAI is clinical, and early stages of the rash present as blanching reticulated erythema in areas associated with heat exposure. If the offending source of heat is not removed, EAI can progress to nonblanching, fixed, hyperpigmented plaques with skin atrophy, bullae, or hyperkeratosis. Patients often are asymptomatic; however, mild burning may occur.2 Histopathology reveals cellular atypia, epidermal atrophy, dilation of dermal blood vessels, a minute inflammatory infiltrate, and keratinocyte apoptosis.10 Skin biopsy may be necessary in cases of suspected malignancy due to chronic heat exposure. Lesions that ulcerate or evolve should raise suspicion for malignancy.11 Squamous cell carcinoma is the most common malignancy associated with EAI; other malignancies that may manifest include basal cell carcinoma, Merkel cell carcinoma, or cutaneous marginal zone lymphoma.2,12-14

Erythema ab igne often is mistaken for livedo reticularis, which appears more erythematous without hyperpigmentation or epidermal changes and may be associated with a pathologic state.15 The differential diagnosis in our patient, who was in her 40s with a history of fatigue and joint pain, included livedo reticularis associated with lupus; however, the history of heating pad use, normal laboratory findings, and presence of epidermal changes suggested EAI. Lupus typically affects the hand and knee joints.16 Additionally, livedo reticularis more commonly appears on the legs.15

Other differentials for EAI include livedo racemosa, cutaneous T-cell lymphoma, and cutis marmorata. Livedo racemosa presents with broken rings of erythema in young to middle-aged women and primarily affects the trunk and proximal limbs. It is associated with an underlying condition such as polyarteritis nodosa and less commonly with lupus erythematosus with antiphospholipid or Sneddon syndrome.15,17 Cutaneous T-cell lymphoma typically manifests with poikilodermatous patches larger than the palm, especially in covered areas of skin.18 Cutis marmorata is transient and temperature dependent.9

The key intervention for EAI is removal of the offending heat source.2 Patients should be counseled that the erythema and hyperpigmentation may take months to years to resolve. Topical hydroquinone or tretinoin may be used in cases of persistent hyperpigmentation.19 Patients who continue to use heating pads for long-standing pain should be advised to limit their use to short intervals without occlusion. If malignancy is a concern, a biopsy should be performed.20

References
  1. Wipf AJ, Brown MR. Malignant transformation of erythema ab igne. JAAD Case Rep. 2022;26:85-87. doi:10.1016/j.jdcr.2022.06.018
  2. Sigmon JR, Cantrell J, Teague D, et al. Poorly differentiated carcinoma arising in the setting of erythema ab igne. Am J Dermatopathol. 2013;35:676-678. doi:10.1097/DAD.0b013e3182871648
  3. Patel DP. The evolving nomenclature of erythema ab igne-redness from fire. JAMA Dermatol. 2017;153:685. doi:10.1001/jamadermatol.2017.2021
  4. Arnold AW, Itin PH. Laptop computer-induced erythema ab igne in a child and review of the literature. Pediatrics. 2010;126:E1227-E1230. doi:10.1542/peds.2010-1390
  5. Riahi RR, Cohen PR. Laptop-induced erythema ab igne: report and review of literature. Dermatol Online J. 2012;18:5.
  6. Haleem Z, Philip J, Muhammad S. Erythema ab igne: a rare presentation of toasted skin syndrome with the use of a space heater. Cureus. 2021;13:e13401. doi:10.7759/cureus.13401
  7. Moreau T, Benzaquen M, Gueissaz F. Erythema ab igne after using a virtual reality headset: a new phenomenon to know. J Eur Acad Dermatol Venereol. 2022;36:E932-E933. doi:10.1111/jdv.18371
  8. Ozturk M, An I. Clinical features and etiology of patients with erythema ab igne: a retrospective multicenter study. J Cosmet Dermatol. 2020;19:1774-1779. doi:10.1111/jocd.13210
  9. Gmuca S, Yu J, Weiss PF, et al. Erythema ab igne in an adolescent with chronic pain: an alarming cutaneous eruption from heat exposure. Pediatr Emerg Care. 2020;36:E236-E238. doi:10.1097 /PEC.0000000000001460
  10. Wells A, Desai A, Rudnick EW, et al. Erythema ab igne with features resembling keratosis lichenoides chronica. J Cutan Pathol. 2021;48:151-153. doi:10.1111/cup.13885
  11. Milchak M, Smucker J, Chung CG, et al. Erythema ab igne due to heating pad use: a case report and review of clinical presentation, prevention, and complications. Case Rep Med. 2016;2016:1862480. doi:10.1155/2016/1862480
  12. Daneshvar E, Seraji S, Kamyab-Hesari K, et al. Basal cell carcinoma associated with erythema ab igne. Dermatol Online J. 2020;26:13030 /qt3kz985b4.
  13. Jones CS, Tyring SK, Lee PC, et al. Development of neuroendocrine (Merkel cell) carcinoma mixed with squamous cell carcinoma in erythema ab igne. Arch Dermatol. 1988;124:110-113.
  14. Wharton J, Roffwarg D, Miller J, et al. Cutaneous marginal zone lymphoma arising in the setting of erythema ab igne. J Am Acad Dermatol. 2010;62:1080-1081. doi:10.1016/j.jaad.2009.08.005
  15. Sajjan VV, Lunge S, Swamy MB, et al. Livedo reticularis: a review of the literature. Indian Dermatol Online J. 2015;6:315-321. doi:10.4103 /2229-5178.164493
  16. Grossman JM. Lupus arthritis. Best Pract Res Clin Rheumatol. 2009;23:495-506. doi:10.1016/j.berh.2009.04.003
  17. Aria AB, Chen L, Silapunt S. Erythema ab igne from heating pad use: a report of three clinical cases and a differential diagnosis. Cureus. 2018;10:E2635. doi:10.7759/cureus.2635
  18. Wilcox RA. Cutaneous T-cell lymphoma: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol. 2017;92:1085-1102. doi:10.1002/ajh.24876
  19. Pennitz A, Kinberger M, Avila Valle G, et al. Self-applied topical interventions for melasma: a systematic review and meta-analysis of data from randomized, investigator-blinded clinical trials. Br J Dermatol. 2022;187:309-317.
  20. Sahl WJ, Taira JW. Erythema ab igne: treatment with 5-fluorouracil cream. J Am Acad Dermatol. 1992;27:109-110.
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Author and Disclosure Information

Dr. Dao is from the Virginia Commonwealth University School of Medicine, Richmond. Dr. Elston is from the Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston.

The authors report no conflict of interest.

Correspondence: Diem-Phuong D. Dao, MD, 1001 E Leigh St, 11th Floor, Richmond, VA 23219 (daopd@vcu.edu).

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Author(s)
Diem-Phuong D. Dao, MD
Dirk M. Elston, MD
Author(s)
Diem-Phuong D. Dao, MD
Dirk M. Elston, MD
Author and Disclosure Information

Dr. Dao is from the Virginia Commonwealth University School of Medicine, Richmond. Dr. Elston is from the Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston.

The authors report no conflict of interest.

Correspondence: Diem-Phuong D. Dao, MD, 1001 E Leigh St, 11th Floor, Richmond, VA 23219 (daopd@vcu.edu).

Author and Disclosure Information

Dr. Dao is from the Virginia Commonwealth University School of Medicine, Richmond. Dr. Elston is from the Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina, Charleston.

The authors report no conflict of interest.

Correspondence: Diem-Phuong D. Dao, MD, 1001 E Leigh St, 11th Floor, Richmond, VA 23219 (daopd@vcu.edu).

Article PDF
CT113006008_e.pdf
Article PDF
CT113006008_e.pdf
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The Diagnosis: Erythema Ab Igne

Based on the patient's long-standing history of back pain treated with heating pads as well as the normal laboratory findings and skin examination, a diagnosis of erythema ab igne (EAI) was made.

Erythema ab igne presents as reticulated brownish erythema or hyperpigmentation on sites exposed to prolonged use of heat sources such as heating pads, laptops, and space heaters. Erythema ab igne most commonly affects the lower back, thighs, or legs1-6; however, EAI can appear on atypical sites such as the forehead and eyebrows due to newer technology (eg, virtual reality headsets).7 The level of heat required for EAI to occur is below the threshold for thermal burns (<45 °C [113 °F]).1 Erythema ab igne can occur at any age, and woman are more commonly affected than men.8 The pathophysiology currently is unknown; however, recurrent and prolonged heat exposure may damage superficial vessels. As a result, hemosiderin accumulates in the skin, and hyperpigmentation subsequently occurs.9

The diagnosis of EAI is clinical, and early stages of the rash present as blanching reticulated erythema in areas associated with heat exposure. If the offending source of heat is not removed, EAI can progress to nonblanching, fixed, hyperpigmented plaques with skin atrophy, bullae, or hyperkeratosis. Patients often are asymptomatic; however, mild burning may occur.2 Histopathology reveals cellular atypia, epidermal atrophy, dilation of dermal blood vessels, a minute inflammatory infiltrate, and keratinocyte apoptosis.10 Skin biopsy may be necessary in cases of suspected malignancy due to chronic heat exposure. Lesions that ulcerate or evolve should raise suspicion for malignancy.11 Squamous cell carcinoma is the most common malignancy associated with EAI; other malignancies that may manifest include basal cell carcinoma, Merkel cell carcinoma, or cutaneous marginal zone lymphoma.2,12-14

Erythema ab igne often is mistaken for livedo reticularis, which appears more erythematous without hyperpigmentation or epidermal changes and may be associated with a pathologic state.15 The differential diagnosis in our patient, who was in her 40s with a history of fatigue and joint pain, included livedo reticularis associated with lupus; however, the history of heating pad use, normal laboratory findings, and presence of epidermal changes suggested EAI. Lupus typically affects the hand and knee joints.16 Additionally, livedo reticularis more commonly appears on the legs.15

Other differentials for EAI include livedo racemosa, cutaneous T-cell lymphoma, and cutis marmorata. Livedo racemosa presents with broken rings of erythema in young to middle-aged women and primarily affects the trunk and proximal limbs. It is associated with an underlying condition such as polyarteritis nodosa and less commonly with lupus erythematosus with antiphospholipid or Sneddon syndrome.15,17 Cutaneous T-cell lymphoma typically manifests with poikilodermatous patches larger than the palm, especially in covered areas of skin.18 Cutis marmorata is transient and temperature dependent.9

The key intervention for EAI is removal of the offending heat source.2 Patients should be counseled that the erythema and hyperpigmentation may take months to years to resolve. Topical hydroquinone or tretinoin may be used in cases of persistent hyperpigmentation.19 Patients who continue to use heating pads for long-standing pain should be advised to limit their use to short intervals without occlusion. If malignancy is a concern, a biopsy should be performed.20

The Diagnosis: Erythema Ab Igne

Based on the patient's long-standing history of back pain treated with heating pads as well as the normal laboratory findings and skin examination, a diagnosis of erythema ab igne (EAI) was made.

Erythema ab igne presents as reticulated brownish erythema or hyperpigmentation on sites exposed to prolonged use of heat sources such as heating pads, laptops, and space heaters. Erythema ab igne most commonly affects the lower back, thighs, or legs1-6; however, EAI can appear on atypical sites such as the forehead and eyebrows due to newer technology (eg, virtual reality headsets).7 The level of heat required for EAI to occur is below the threshold for thermal burns (<45 °C [113 °F]).1 Erythema ab igne can occur at any age, and woman are more commonly affected than men.8 The pathophysiology currently is unknown; however, recurrent and prolonged heat exposure may damage superficial vessels. As a result, hemosiderin accumulates in the skin, and hyperpigmentation subsequently occurs.9

The diagnosis of EAI is clinical, and early stages of the rash present as blanching reticulated erythema in areas associated with heat exposure. If the offending source of heat is not removed, EAI can progress to nonblanching, fixed, hyperpigmented plaques with skin atrophy, bullae, or hyperkeratosis. Patients often are asymptomatic; however, mild burning may occur.2 Histopathology reveals cellular atypia, epidermal atrophy, dilation of dermal blood vessels, a minute inflammatory infiltrate, and keratinocyte apoptosis.10 Skin biopsy may be necessary in cases of suspected malignancy due to chronic heat exposure. Lesions that ulcerate or evolve should raise suspicion for malignancy.11 Squamous cell carcinoma is the most common malignancy associated with EAI; other malignancies that may manifest include basal cell carcinoma, Merkel cell carcinoma, or cutaneous marginal zone lymphoma.2,12-14

Erythema ab igne often is mistaken for livedo reticularis, which appears more erythematous without hyperpigmentation or epidermal changes and may be associated with a pathologic state.15 The differential diagnosis in our patient, who was in her 40s with a history of fatigue and joint pain, included livedo reticularis associated with lupus; however, the history of heating pad use, normal laboratory findings, and presence of epidermal changes suggested EAI. Lupus typically affects the hand and knee joints.16 Additionally, livedo reticularis more commonly appears on the legs.15

Other differentials for EAI include livedo racemosa, cutaneous T-cell lymphoma, and cutis marmorata. Livedo racemosa presents with broken rings of erythema in young to middle-aged women and primarily affects the trunk and proximal limbs. It is associated with an underlying condition such as polyarteritis nodosa and less commonly with lupus erythematosus with antiphospholipid or Sneddon syndrome.15,17 Cutaneous T-cell lymphoma typically manifests with poikilodermatous patches larger than the palm, especially in covered areas of skin.18 Cutis marmorata is transient and temperature dependent.9

The key intervention for EAI is removal of the offending heat source.2 Patients should be counseled that the erythema and hyperpigmentation may take months to years to resolve. Topical hydroquinone or tretinoin may be used in cases of persistent hyperpigmentation.19 Patients who continue to use heating pads for long-standing pain should be advised to limit their use to short intervals without occlusion. If malignancy is a concern, a biopsy should be performed.20

References
  1. Wipf AJ, Brown MR. Malignant transformation of erythema ab igne. JAAD Case Rep. 2022;26:85-87. doi:10.1016/j.jdcr.2022.06.018
  2. Sigmon JR, Cantrell J, Teague D, et al. Poorly differentiated carcinoma arising in the setting of erythema ab igne. Am J Dermatopathol. 2013;35:676-678. doi:10.1097/DAD.0b013e3182871648
  3. Patel DP. The evolving nomenclature of erythema ab igne-redness from fire. JAMA Dermatol. 2017;153:685. doi:10.1001/jamadermatol.2017.2021
  4. Arnold AW, Itin PH. Laptop computer-induced erythema ab igne in a child and review of the literature. Pediatrics. 2010;126:E1227-E1230. doi:10.1542/peds.2010-1390
  5. Riahi RR, Cohen PR. Laptop-induced erythema ab igne: report and review of literature. Dermatol Online J. 2012;18:5.
  6. Haleem Z, Philip J, Muhammad S. Erythema ab igne: a rare presentation of toasted skin syndrome with the use of a space heater. Cureus. 2021;13:e13401. doi:10.7759/cureus.13401
  7. Moreau T, Benzaquen M, Gueissaz F. Erythema ab igne after using a virtual reality headset: a new phenomenon to know. J Eur Acad Dermatol Venereol. 2022;36:E932-E933. doi:10.1111/jdv.18371
  8. Ozturk M, An I. Clinical features and etiology of patients with erythema ab igne: a retrospective multicenter study. J Cosmet Dermatol. 2020;19:1774-1779. doi:10.1111/jocd.13210
  9. Gmuca S, Yu J, Weiss PF, et al. Erythema ab igne in an adolescent with chronic pain: an alarming cutaneous eruption from heat exposure. Pediatr Emerg Care. 2020;36:E236-E238. doi:10.1097 /PEC.0000000000001460
  10. Wells A, Desai A, Rudnick EW, et al. Erythema ab igne with features resembling keratosis lichenoides chronica. J Cutan Pathol. 2021;48:151-153. doi:10.1111/cup.13885
  11. Milchak M, Smucker J, Chung CG, et al. Erythema ab igne due to heating pad use: a case report and review of clinical presentation, prevention, and complications. Case Rep Med. 2016;2016:1862480. doi:10.1155/2016/1862480
  12. Daneshvar E, Seraji S, Kamyab-Hesari K, et al. Basal cell carcinoma associated with erythema ab igne. Dermatol Online J. 2020;26:13030 /qt3kz985b4.
  13. Jones CS, Tyring SK, Lee PC, et al. Development of neuroendocrine (Merkel cell) carcinoma mixed with squamous cell carcinoma in erythema ab igne. Arch Dermatol. 1988;124:110-113.
  14. Wharton J, Roffwarg D, Miller J, et al. Cutaneous marginal zone lymphoma arising in the setting of erythema ab igne. J Am Acad Dermatol. 2010;62:1080-1081. doi:10.1016/j.jaad.2009.08.005
  15. Sajjan VV, Lunge S, Swamy MB, et al. Livedo reticularis: a review of the literature. Indian Dermatol Online J. 2015;6:315-321. doi:10.4103 /2229-5178.164493
  16. Grossman JM. Lupus arthritis. Best Pract Res Clin Rheumatol. 2009;23:495-506. doi:10.1016/j.berh.2009.04.003
  17. Aria AB, Chen L, Silapunt S. Erythema ab igne from heating pad use: a report of three clinical cases and a differential diagnosis. Cureus. 2018;10:E2635. doi:10.7759/cureus.2635
  18. Wilcox RA. Cutaneous T-cell lymphoma: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol. 2017;92:1085-1102. doi:10.1002/ajh.24876
  19. Pennitz A, Kinberger M, Avila Valle G, et al. Self-applied topical interventions for melasma: a systematic review and meta-analysis of data from randomized, investigator-blinded clinical trials. Br J Dermatol. 2022;187:309-317.
  20. Sahl WJ, Taira JW. Erythema ab igne: treatment with 5-fluorouracil cream. J Am Acad Dermatol. 1992;27:109-110.
References
  1. Wipf AJ, Brown MR. Malignant transformation of erythema ab igne. JAAD Case Rep. 2022;26:85-87. doi:10.1016/j.jdcr.2022.06.018
  2. Sigmon JR, Cantrell J, Teague D, et al. Poorly differentiated carcinoma arising in the setting of erythema ab igne. Am J Dermatopathol. 2013;35:676-678. doi:10.1097/DAD.0b013e3182871648
  3. Patel DP. The evolving nomenclature of erythema ab igne-redness from fire. JAMA Dermatol. 2017;153:685. doi:10.1001/jamadermatol.2017.2021
  4. Arnold AW, Itin PH. Laptop computer-induced erythema ab igne in a child and review of the literature. Pediatrics. 2010;126:E1227-E1230. doi:10.1542/peds.2010-1390
  5. Riahi RR, Cohen PR. Laptop-induced erythema ab igne: report and review of literature. Dermatol Online J. 2012;18:5.
  6. Haleem Z, Philip J, Muhammad S. Erythema ab igne: a rare presentation of toasted skin syndrome with the use of a space heater. Cureus. 2021;13:e13401. doi:10.7759/cureus.13401
  7. Moreau T, Benzaquen M, Gueissaz F. Erythema ab igne after using a virtual reality headset: a new phenomenon to know. J Eur Acad Dermatol Venereol. 2022;36:E932-E933. doi:10.1111/jdv.18371
  8. Ozturk M, An I. Clinical features and etiology of patients with erythema ab igne: a retrospective multicenter study. J Cosmet Dermatol. 2020;19:1774-1779. doi:10.1111/jocd.13210
  9. Gmuca S, Yu J, Weiss PF, et al. Erythema ab igne in an adolescent with chronic pain: an alarming cutaneous eruption from heat exposure. Pediatr Emerg Care. 2020;36:E236-E238. doi:10.1097 /PEC.0000000000001460
  10. Wells A, Desai A, Rudnick EW, et al. Erythema ab igne with features resembling keratosis lichenoides chronica. J Cutan Pathol. 2021;48:151-153. doi:10.1111/cup.13885
  11. Milchak M, Smucker J, Chung CG, et al. Erythema ab igne due to heating pad use: a case report and review of clinical presentation, prevention, and complications. Case Rep Med. 2016;2016:1862480. doi:10.1155/2016/1862480
  12. Daneshvar E, Seraji S, Kamyab-Hesari K, et al. Basal cell carcinoma associated with erythema ab igne. Dermatol Online J. 2020;26:13030 /qt3kz985b4.
  13. Jones CS, Tyring SK, Lee PC, et al. Development of neuroendocrine (Merkel cell) carcinoma mixed with squamous cell carcinoma in erythema ab igne. Arch Dermatol. 1988;124:110-113.
  14. Wharton J, Roffwarg D, Miller J, et al. Cutaneous marginal zone lymphoma arising in the setting of erythema ab igne. J Am Acad Dermatol. 2010;62:1080-1081. doi:10.1016/j.jaad.2009.08.005
  15. Sajjan VV, Lunge S, Swamy MB, et al. Livedo reticularis: a review of the literature. Indian Dermatol Online J. 2015;6:315-321. doi:10.4103 /2229-5178.164493
  16. Grossman JM. Lupus arthritis. Best Pract Res Clin Rheumatol. 2009;23:495-506. doi:10.1016/j.berh.2009.04.003
  17. Aria AB, Chen L, Silapunt S. Erythema ab igne from heating pad use: a report of three clinical cases and a differential diagnosis. Cureus. 2018;10:E2635. doi:10.7759/cureus.2635
  18. Wilcox RA. Cutaneous T-cell lymphoma: 2017 update on diagnosis, risk-stratification, and management. Am J Hematol. 2017;92:1085-1102. doi:10.1002/ajh.24876
  19. Pennitz A, Kinberger M, Avila Valle G, et al. Self-applied topical interventions for melasma: a systematic review and meta-analysis of data from randomized, investigator-blinded clinical trials. Br J Dermatol. 2022;187:309-317.
  20. Sahl WJ, Taira JW. Erythema ab igne: treatment with 5-fluorouracil cream. J Am Acad Dermatol. 1992;27:109-110.
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A 42-year-old woman presented with an asymptomatic, erythematous, lacelike rash on the lower back of 8 months’ duration that was first noticed by her husband. The patient had a long-standing history of chronic fatigue and lower back pain treated with acetaminophen, diclofenac gel, and heating pads. Physical examination revealed reticulated brownish erythema confined to the lower back. Laboratory findings were unremarkable.

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