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Dermatology > ENVIRONMENTAL
Erythema Ab Igne
Article Last Updated: Feb 27, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 9  
Author: Robert S Bader, MD, Assistant Clinical Professor, Department of Dermatology, Hahnemann Hospital
Robert S Bader is a member of the following medical societies: American Academy of Dermatology, American Society for Dermatologic Surgery, and American Society for MOHS Surgery
Editors: Marjan Garmyn, MD, PhD, Professor, Faculty of Medicine, Katholieke Universiteit Leuven, Belgium; Chair and Adjunct Head, Department of Dermatology, University of Leuven, Belgium; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; Edward F Chan, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Catherine Quirk, MD, Clinical Assistant Professor, Department of Dermatology, Brown University; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Author and Editor Disclosure
Synonyms and related keywords:
erythema ab igne elastosis, ephelis ab igne, erythema à calore, toasted skin syndrome, erythema a calore
Background
Erythema ab igne (EAI) occurs in skin that is chronically and repeatedly exposed to infrared radiation. EAI results in persistent, reticulate, erythematous patches; telangiectasia; and hyperpigmentation.
Pathophysiology
EAI is caused by chronic repeated exposure to moderate heat from an external heat source. The exposure, which need not be of long duration, results in cutaneous hyperthermia in the range of 43-47°C, which, in turn, results in histopathologic changes similar to those seen in solar-damaged skin. Although the pathogenic mechanisms in EAI are poorly understood, one study has shown that moderate heat acts synergistically with ultraviolet radiation to denature DNA in squamous cells in vitro.
Frequency
United States
Rare
Mortality/Morbidity
Chronic repeated exposure to infrared radiation may result in changes similar to those seen with chronic repeated ultraviolet radiation. Thermal keratosis, squamous cell carcinoma in situ, and squamous cell carcinoma have been reported in patients after chronic exposure to infrared radiation. In one 90-year-old woman with EAI, Merkel cell carcinoma developed adjacent to squamous cell carcinoma.
Sex
Women, in particular those who are overweight, are affected more often than men.
History
Commonly, patients report mild pruritus and burning.
Physical
Mild elevation of skin temperature initially results in mild, transient, often reticulated erythema. With prolonged and repeated exposure, areas of reticular erythema persist and, in time, become livid and hyperpigmented. Rarely, affected areas may become bullous or hyperkeratotic; in patients with severe long-standing EAI, poikilodermatous changes may result. Some believe that a bullous variant of EAI exists, in which bullae and crusts are present on a base of reticulated erythema.
Causes
The following have been reported as heat sources that resulted in the development of EAI:
- Open fires reportedly result in EAI.
- Typically, EAI affects the legs of women aged 40-70 years who use indoor fire as a heat source.
- EAI reportedly affects the face and/or palms of cooks who work over an open fire.
- Some patients use a heat source (eg, heating pad, hot water bottle, heated recliner) to relieve chronic pain. In these patients, determine the etiology of the pain.
- Heating pads and/or hot water bottles: EAI occurs in patients with pain associated with either primary or metastatic malignancy, as well as with pain associated with chronic pancreatitis.
- Heated recliners (reclining chairs): EAI has been reported in patients with chronic lower back pain.
- A car heater reportedly caused EAI in one patient.
- The application of heated popcorn kernels applied to the skin to reduce arthritic pain caused EAI in one patient.
- More recently, using laptop computers while they are propped on the legs has resulted in the development of EAI. Some laptop computers can generate significant heat that can result in EAI when placed on the lap for prolonged periods.
Acanthosis Nigricans
Other Problems to be Considered
Livedo reticularis
Livedoid vasculitis
Poikiloderma atrophicans vasculare
Procedures
- Perform a 3- or 4-mm punch biopsy if the diagnosis is uncertain.
Histologic Findings
In early lesions, epidermal atrophy with loss of the rete ridges is seen. Later, melanin incontinence occurs with melanophages present in the upper dermis.
Collagen degeneration and a relative increase in dermal elastic tissue are seen. In contrast to solar elastosis, this is not basophilic on hematoxylin and eosin–stained specimens.
Telangiectasis within the papillary dermis and occasional hemosiderin may be seen more commonly on the legs.
Some patients show focal or confluent hyperkeratosis, dyskeratosis, keratinocyte atypia, and, occasionally, melanocyte atypia.
Surgical Care
In patients with chronic EAI that results in hyperpigmentation, photothermolysis using the Nd:YAG, ruby, or alexandrite laser may improve the appearance of these lesions.
Activity
Cessation of chronic heat exposure is paramount. In mildly affected patients with little or no pigmentary change, their condition may resolve within several months.
Further Outpatient Care
- As in patients with chronic solar damage, monitor patients with EAI at regular intervals for possible development of thermal keratosis, squamous cell carcinoma in situ, and squamous cell carcinoma. In addition, although not yet reported, other cutaneous malignancies (eg, malignant melanoma) feasibly may develop within the affected areas.
Prognosis
- Early changes, such as erythema and little or no hyperpigmentation, may resolve within several months.
- Chronic and repeated exposure to heat may result in such permanent changes as hyperpigmentation and atrophy.
- In addition, thermal keratosis, squamous cell carcinoma in situ, and squamous cell carcinoma have been reported within these lesions.
Patient Education
- Explain the etiology of the disorder to patients, and emphasize that the cessation of heat exposure is paramount.
- Inform patients about the possibility of malignant degeneration in the affected areas. Educate patients about detection and the need for prompt treatment.
Medical/Legal Pitfalls
- Failure to monitor patients regularly and to inform them of the possibility of malignant degeneration (eg, thermal keratosis, squamous cell carcinoma in situ, squamous cell carcinoma)
- Failure to determine the etiology of pain in patients who use heat to relieve chronic pain since EAI reportedly has occurred in patients with primary or metastatic malignancies and in patients with chronic pancreatitis
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Erythema Ab Igne excerpt Article Last Updated: Feb 27, 2007
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