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|Year : 2013 | Volume
| Issue : 1 | Page : 56-57
Erythema ab igne of shins: A kerosene stove-induced prototype in diabetics
Y Milgrom1, T Sabag1, A Zlotogorski2, SN Heyman1
1 Department of Medicine, Hadassah Hebrew University Hospitals, Jerusalem, Israel
2 Department of Dermatology, Hadassah Hebrew University Hospitals, Jerusalem, Israel
|Date of Submission||19-Jul-2012|
|Date of Decision||05-Oct-2012|
|Date of Acceptance||09-Oct-2012|
|Date of Web Publication||22-Mar-2013|
S N Heyman
Department of Medicine, Hadassah Hebrew University Hospitals, Jerusalem
A patient with erythema ab igne of shins is presented, caused by repeated thermal injury induced by a heating stove placed between the knees. This injury pattern has been repeatedly identified in diabetic patients involved in similar heating practice, underscoring a possible predisposition related to diabetic neuropathy.
Keywords: Diabetes, erythema ab igne, neuropathy, thermal injury
|How to cite this article:|
Milgrom Y, Sabag T, Zlotogorski A, Heyman S N. Erythema ab igne of shins: A kerosene stove-induced prototype in diabetics. J Postgrad Med 2013;59:56-7
|How to cite this URL:|
Milgrom Y, Sabag T, Zlotogorski A, Heyman S N. Erythema ab igne of shins: A kerosene stove-induced prototype in diabetics. J Postgrad Med [serial online] 2013 [cited 2014 Sep 22];59:56-7. Available from: http://www.jpgmonline.com/text.asp?2013/59/1/56/109498
| :: Introduction|| |
A 72-years-old male patient of Arab origin with hypertension, long-standing type II diabetes and diabetic neuropathy (manifested by long-standing glove and stocking hypo-aesthesia, and the loss of distal proprioception and deep tendon reflexes), presented with hemorrhagic stroke. Peculiar reticulated pigmented non-tender and non-blanching lesions were noted in the inner upper aspects of both shins [Figure 1]. Similar lesions were noted in additional three old diabetic Arab patients. Interestingly, they all reported using kerosene stove placed between their knees in cold weather.
|Figure 1: Typical erythema ab igne lesions with reticulate erythema and brownish hyperpigmentation, with subsequent lichenification in regions repeatedly subjected to thermal injury by a kerosene stove placed between the legs in wintertime|
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The differential diagnosis of these lesions include livedo reticularis, livedoid vasculitis, diabetic shin dermopathy, or poikiloderma atrophicans vasculare. , Yet, this peculiar distribution pattern of shin dermopathy in our series is characteristic of erythema ab igne, skin lesions induced by repeated dermal thermal injuries,  conceivably related to traditional warming practice among the old generation of the Arab population. Indeed, pre-tibial erythema ab igne has classically been described in women sitting in front of open fire or stove, but with the introduction of modern heating systems in developed countries erythema ab igne nowadays is mostly noted at specific skin regions warmed repeatedly by heating pads, heated car seats or laptop computers. ,, In the same fashion, erythema ab igne may develop following repeated heat applications for pain relief, for instance in patients with malignancies. 
| :: Discussion|| |
Erythema ab igne, nicknamed "toasted skin", is characterized by persistent reticulate erythema with blue, purple or brown non-blanchable hyperpigmentation of the skin, occasionally associated with lichenification. It is usually asymptomatic but may be associated with mild pruritus and burning sensation.  Transient repeated elevation of skin temperature to 43-47°C inflict DNA damage in keratocytes, leading to histopathologic changes resembling solar keratosis, that may predispose to the development of squamous cell or merkel cell carcinoma. 
As suggested in a single previous case report,  it is tempting to assume that diabetic neuropathy associated with reduced pain and temperature sensation might have predisposed to erythema ab igne in our patients, practicing old heating techniques. Indeed, one of our patients developed a thermal injury with a small 3 rd degree burn within a much wider region with a typical erythema ab igne lesion.
Eliminating exposure to the heat source may reverse erythema ab igne lesions at their early phase with complete resolution. Tretinoin may be used for more advanced cases, and epithelial atypia might be managed with 5-fluorouracil cream.  Our small series suggest that special attention is warranted specifically in diabetics practicing the use of heating devices.
| :: References|| |
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