Table 5. Comparison of Clinical Characteristics and Outcomes among the Three Cases

Characteristic Case 1 Case 2 Case 3
Age/sex 43/F 48/F 43/F
Time from weight-management program initiation to onset 5 days 25 days 10 days
Time from herbal pill and LCD initiation to onset 3 days 22 days 7 days
Lesion site Bilateral flank and lower back Upper chest, axillae, lateral chest, flank, and lower back Right lateral upper arm
Main morphology Polymorphic erythematous papules Extensive round or annular erythematous papules and plaques Localized erythematous papules or papular plaques
Peak itch NRS 2/10 1/10 4/10
Carbohydrate intake before onset ≤12 g/meal ≤12 g/meal ≤12 g/meal
Carbohydrate intake after onset Approximately 30 g/meal Approximately 30 g/meal Approximately 30 g/meal
Urine ketone findings around onset Negative 5 days before and 30 days after onset; intermittently positive during later follow-up ±5 at 7 days after onset; negative at 34 and 69 days after onset +15 at 10 days before onset; ±5 at 12 days after onset; intermittently positive during later follow-up
Topical treatment 紫雲膏 (Jaun-go) 紫雲膏 (Jaun-go) 紫雲膏 (Jaun-go)
Decoction modification after onset Changed to 十味敗毒散(Sipmipaedok-san) Changed to 十味敗毒散(Sipmipaedok-san) 7 days after onset No change for lesion management
Clinical course Markedly improved by Day 8; normal skin by approximately 1 month Lesions expanded through Day 7; active lesions mostly resolved by approximately 5 weeks Active lesions mostly resolved by Day 12
Residual hyperpigmentation Faint pigmentation at Day 8; no persistent reticulated hyperpigmentation Reticulated hyperpigmentation, subsequently resolved Faint localized pigmentation
Ephedra dose at onset 7.5 g/day 11.7 g/day 9.6 g/day
Maximum Ephedra dose during follow-up 18.0 g/day 18.0 g/day 18.0 g/day
Recurrence during follow-up No No No
Weight change -5.8 kg -6.3 kg -3.5 kg
LCD, low-carbohydrate diet; NRS, Numeric Rating Scale. Urine ketone tests were performed during routine follow-up and were not timed specifically to lesion onset. Therefore, the results do not necessarily represent the ketotic state at the time of lesion development.