Prurigo pigmentosa is a rare skin condition of unknown cause, characterized by the sudden onset of erythematouspapules that leave a reticulated hyperpigmentation when they heal.[1]: 57 The condition has been associated with a strict ketogenic diet in case reports in the medical literature.[2][3] It was first reported by Masaharu Nagashima in 1978.[4] Research has shown that it may be caused by gut bacteria dysbiosis as a result of ketosis.[5][6]