What are the common causes of anemia rash. How can you identify anemia rash symptoms. What are the most effective treatment options for anemia rash. When should you seek medical attention for an anemia-related skin condition.

Understanding Anemia and Its Impact on Skin Health

Anemia is a condition characterized by an abnormally low count of red blood cells, which are responsible for transporting oxygen throughout the body. This deficiency can manifest in various ways, including skin abnormalities. Anemia rashes are one such manifestation, appearing as a result of the anemia itself or as a side effect of anemia treatment.

The appearance of anemia rashes can vary significantly, ranging from small, pinpoint red or purple spots to larger bruise-like marks or red bumps. Understanding the connection between anemia and skin health is crucial for proper diagnosis and treatment.

Types of Anemia Associated with Skin Rashes

• Aplastic anemia
• Thrombotic thrombocytopenic purpura
• Paroxysmal nocturnal hemoglobinuria
• Hemolytic uremic syndrome
• Iron deficiency anemia

Aplastic Anemia: A Common Cause of Anemia Rashes

Aplastic anemia is one of the most frequent causes of anemia-related skin rashes. This rare but serious condition can be either acquired or inherited, and it primarily affects teenagers and older adults. Interestingly, it is two to three times more prevalent in Asian countries compared to other regions worldwide.

In aplastic anemia, the body’s bone marrow fails to produce sufficient new blood cells. This deficiency leads to a characteristic rash known as petechiae, which appears as patches of pinpoint red or purple spots. These spots can be either raised or flat and are commonly found on the neck, arms, and legs.

Identifying Petechiae

• Pinpoint red or purple spots
• Can be raised or flat
• Usually appear on neck, arms, and legs
• Do not blanch when pressed
• Generally painless and non-itchy

Why do petechiae occur in aplastic anemia? The condition not only causes a shortage of red blood cells but also leads to a lower than normal platelet count. Platelets are crucial for blood clotting, and their deficiency results in easier bruising and bleeding, contributing to the appearance of rash-like bruises.

Thrombotic Thrombocytopenic Purpura: A Rare Blood Disorder

Thrombotic thrombocytopenic purpura (TTP) is an uncommon blood disorder that causes tiny blood clots to form throughout the body. This condition can lead to the development of petechiae, similar to those seen in aplastic anemia. Additionally, TTP can cause unexplained purplish bruising that resembles a rash, known as purpura.

How does TTP differ from other anemia-related skin conditions? Unlike some other forms of anemia, TTP is characterized by the formation of blood clots, which can lead to more severe complications if left untreated. The combination of petechiae and purpura in TTP can create a distinctive pattern on the skin, helping healthcare providers in their diagnosis.

Paroxysmal Nocturnal Hemoglobinuria: A Genetic Disorder Affecting Red Blood Cells

Paroxysmal nocturnal hemoglobinuria (PNH) is an extremely rare genetic disorder that affects the production of red blood cells. In PNH, a genetic mutation causes the body to produce abnormal red blood cells that break down too quickly. This rapid breakdown can lead to blood clots and unexplained bruising, which may appear as a rash-like condition on the skin.

What sets PNH apart from other anemia-related skin conditions? The genetic nature of PNH means that it is not acquired like some other forms of anemia. The bruising associated with PNH can be particularly challenging to diagnose, as it may not follow typical patterns seen in other blood disorders.

Hemolytic Uremic Syndrome: When the Immune System Attacks Red Blood Cells

Hemolytic uremic syndrome (HUS) is a condition in which an immune reaction causes the destruction of red blood cells. This immune response can be triggered by various factors, including bacterial infections, certain medications, and even pregnancy. HUS can manifest on the skin as small, unexplained bruising and swelling, particularly affecting the face, hands, or feet.

How does HUS differ from other anemia-related skin conditions? The immune-mediated nature of HUS sets it apart from other forms of anemia. The swelling associated with HUS, especially in the facial area, can be a distinguishing feature that helps in its identification.

Common Triggers for Hemolytic Uremic Syndrome

• Bacterial infections (e.g., E. coli)
• Certain medications
• Pregnancy
• Autoimmune disorders
• Genetic predisposition

Iron Deficiency Anemia: A Common Cause with Unique Skin Manifestations

Iron deficiency anemia is one of the most prevalent types of anemia worldwide. While it may not directly cause a rash in the same way as some other forms of anemia, it can lead to skin-related symptoms. People with iron deficiency often develop pruritus, which is the medical term for itchy skin. This itchiness can lead to scratching, resulting in redness and bumps that may resemble a rash.

Interestingly, the treatment for iron deficiency anemia can sometimes cause rashes as well. Ferrous sulfate, a common iron supplement prescribed for this condition, can occasionally trigger an allergic reaction in some individuals. This reaction may manifest as an itchy rash or hives, potentially accompanied by skin swelling beneath the affected areas.

Symptoms of Iron Deficiency Anemia

• Pale skin
• Fatigue
• Shortness of breath
• Itchy skin (pruritus)
• Brittle nails
• Headaches
• Cold hands and feet

When should you seek medical attention for a suspected iron supplement allergy? If you develop hives or an itchy rash after starting iron supplements, especially if accompanied by swelling of the lips, tongue, or throat, it’s crucial to seek immediate medical care. These symptoms could indicate a severe allergic reaction that requires prompt treatment.

Diagnosing Anemia-Related Skin Conditions

Diagnosing anemia-related skin conditions requires a comprehensive approach. Healthcare providers typically consider the physical appearance of the rash alongside other common anemia symptoms. These may include pale skin, fatigue, and shortness of breath. In cases where aplastic anemia is suspected, doctors will also look for additional symptoms such as rapid or irregular heartbeat, unexplained bruising, prolonged bleeding from cuts, dizziness, headaches, nosebleeds, bleeding gums, and frequent infections.

What diagnostic tests are used to confirm anemia-related skin conditions? While the appearance of the rash and associated symptoms can provide valuable clues, definitive diagnosis often requires blood tests. These may include a complete blood count (CBC), iron studies, and specialized tests to identify specific types of anemia or related blood disorders.

When to Seek Medical Attention for a Rash

1. The rash appears suddenly and severely without explanation
2. The rash covers your entire body
3. The rash persists for more than two weeks despite home treatment
4. You experience additional symptoms like fatigue, fever, weight loss, or changes in bowel movements
5. You suspect an allergic reaction to iron supplements

Treatment Options for Anemia-Related Skin Conditions

The most effective approach to treating anemia rashes is to address the underlying condition causing them. Treatment strategies vary depending on the specific type of anemia and its severity. For iron deficiency anemia, iron supplementation is typically the primary treatment, although care must be taken to monitor for potential allergic reactions.

In cases of aplastic anemia, treatment may involve blood transfusions, immunosuppressive therapy, or even bone marrow transplantation in severe cases. For conditions like thrombotic thrombocytopenic purpura or hemolytic uremic syndrome, plasma exchange (plasmapheresis) may be necessary to remove harmful antibodies from the blood.

Complementary Approaches to Managing Anemia-Related Skin Symptoms

• Gentle skin care routines to minimize irritation
• Avoiding hot showers or baths that can exacerbate itching
• Using fragrance-free, hypoallergenic moisturizers
• Wearing soft, breathable fabrics to reduce skin irritation
• Maintaining proper hydration to support overall skin health

How long does it take for anemia-related skin conditions to improve with treatment? The timeline for improvement can vary significantly depending on the underlying cause and the chosen treatment approach. Some individuals may see improvements within a few weeks of starting treatment, while others may require several months of consistent therapy before noticing significant changes in their skin condition.

Preventing Anemia-Related Skin Conditions

While not all cases of anemia-related skin conditions can be prevented, there are steps you can take to reduce your risk. Maintaining a balanced diet rich in iron, vitamin B12, and folate can help prevent nutritional anemias. Regular health check-ups and blood tests can also aid in early detection and treatment of anemia before skin manifestations occur.

For individuals with known anemia or a predisposition to certain types of anemia, working closely with a healthcare provider to manage the condition effectively is crucial. This may involve regular monitoring, adherence to prescribed treatments, and prompt reporting of any new symptoms or concerns.

Dietary Sources of Iron, Vitamin B12, and Folate

• Iron: Red meat, poultry, fish, beans, lentils, spinach
• Vitamin B12: Eggs, milk, cheese, fortified cereals, fish, meat
• Folate: Leafy green vegetables, citrus fruits, beans, fortified grains

Can lifestyle changes help prevent anemia-related skin conditions? While lifestyle modifications alone may not prevent all types of anemia, they can play a significant role in maintaining overall health and potentially reducing the risk of certain forms of anemia. Regular exercise, stress management, and avoiding excessive alcohol consumption can all contribute to better blood health and, by extension, healthier skin.

Anemia Rash: Causes, Pictures, and Treatment

An anemia rash may be caused by the anemia itself or due to complications from treatment for anemia. Depending on the type and cause, the rash may look like red or purple pinpoint spots, a bruise, or red bumps.

There are many different types of anemias with different causes. They all have the same effect on the body: an abnormally low amount of red blood cells. Red blood cells are responsible for carrying oxygen through the body.

Some types of anemia can cause rashes, which are abnormalities on the skin. Sometimes, the rash that presents with anemia may be due to the anemia condition itself. Other times, the rash may be due to complications from the treatment of the anemia.

Aplastic anemia

Aplastic anemia is one of the most common causes of anemia rashes. Aplastic anemia is a rare condition, but it can be serious. It can develop or be inherited. It’s most often seen in teenagers and older adults. According to the National Heart, Lung, and Blood Institute, it’s two to three times more common in Asian countries than anywhere else in the world.

Aplastic anemia occurs when the body’s bone marrow doesn’t make enough new blood cells. The rashes resemble patches of pinpoint red or purple spots, known as petechiae. These red spots may be raised or flat on the skin. They can appear anywhere on the body but are more common on the neck, arms, and legs.

The petechial red spots do not typically cause any symptoms like pain or itching. You should notice that they stay red, even if you press on the skin.

In aplastic anemia, not only is there a shortage of red blood cells, there is also a lower than normal level of platelets, another type of blood cell. Low platelet count tends to result in bruising or bleeding more easily. This leads to bruises that look like rashes.

Thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura is a rare blood disorder that causes tiny blood clots to form throughout your body. This can cause the tiny red or purple spots known as petechiae, as well as unexplained purplish bruising that can look like a rash. The bruising is known as purpura.

Paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria is a very rare genetic disorder in which a genetic mutation causes your body to produce abnormal red blood cells that break down too quickly. This can cause blood clots and unexplained bruising.

Hemolytic uremic syndrome

Hemolytic uremic syndrome is a condition in which an immune reaction causes the destruction of red blood cells. The immune reaction can be triggered by bacterial infections, some medications, and even pregnancy. It can cause small, unexplained bruising and swelling, particularly of your face, hands, or feet.

Other causes

Iron deficiency anemia is one of the most common types of anemia. People with iron deficiency of any kind may develop pruritus, which is the medical term for itchy skin. As you itch, you may scratch your skin, which can cause redness and bumps that look like rashes.

In some cases, treatment for iron deficiency anemia may also cause rashes. Ferrous sulfate is a type of iron supplement that your doctor may prescribe to you if you have iron deficiency anemia. Some people may develop an allergy to the ferrous sulfate therapy. This can cause you to develop an itchy rash and hives. The hives or rash can appear anywhere on the body and may also come with some skin swelling under the red areas.

You should seek medical attention immediately if you think you have hives or an allergic rash due to ferrous sulfate, especially if you experience any swelling of the lips, tongue, or throat.

Your doctor may suspect anemia as the cause of your rash if it meets the physical description and is accompanied with other common anemia symptoms. These include:

• pale skin
• fatigue
• shortness of breath

Your doctor may check you for aplastic anemia if you display symptoms like:

• rapid or irregular heartbeat
• unexplained, easy bruising
• prolonged bleeding from cuts, especially minor ones
• dizziness and headaches
• nosebleeds
• bleeding gums
• frequent infections, especially those that take longer to clear up than normal

If you’re experiencing a rash or skin changes, you should make an appointment to see your doctor or dermatologist, especially if:

• the rash is severe and comes on suddenly with no explanation
• the rash covers your whole body
• the rash lasts more than two weeks and hasn’t improved with home treatment
• you also experience other symptoms like tiredness, fever, weight loss, or changes in bowel movements

If you believe that the rash is a reaction to new iron supplements that you’ve started taking, seek immediate medical attention. You could be having an allergic reaction or may be taking too high of a dose.

The best ways to treat anemia rashes is to treat the underlying conditions causing them. If your doctor suspects or diagnoses iron deficiency as a cause, they will likely have you start taking iron supplements.

Treating aplastic anemia is sometimes more difficult. Treatments used in aplastic anemia include:

Blood transfusions: Blood transfusions can reduce symptoms but not cure aplastic anemia. You may get a transfusion of both red blood cells and platelets. There isn’t a limit to the number of blood transfusions you can receive. However, they may become less effective over time as your body develops antibodies against transfused blood.

Immunosuppressant drugs: These medications suppress the damage that immune cells are doing to your bone marrow. This allows the bone marrow to recover and create more blood cells.

Stem cell transplants: These can help rebuild the bone marrow to the point where it creates enough blood cells.

Anemia can’t be prevented, so the best way to try to prevent anemia rashes is to treat the underlying causes. Make sure you’re getting enough iron through your diet or with supplements to prevent iron deficiency anemia and iron deficiency-related pruritus.

If you develop an unexplained rash, see your doctor right away. If you don’t already have a provider, our Healthline FindCare tool can help you connect to physicians in your area.

Keep reading: The top 10 foods high in iron »

Anemia Rash: Causes, Pictures, and Treatment

An anemia rash may be caused by the anemia itself or due to complications from treatment for anemia. Depending on the type and cause, the rash may look like red or purple pinpoint spots, a bruise, or red bumps.

There are many different types of anemias with different causes. They all have the same effect on the body: an abnormally low amount of red blood cells. Red blood cells are responsible for carrying oxygen through the body.

Some types of anemia can cause rashes, which are abnormalities on the skin. Sometimes, the rash that presents with anemia may be due to the anemia condition itself. Other times, the rash may be due to complications from the treatment of the anemia.

Aplastic anemia

Aplastic anemia is one of the most common causes of anemia rashes. Aplastic anemia is a rare condition, but it can be serious. It can develop or be inherited. It’s most often seen in teenagers and older adults. According to the National Heart, Lung, and Blood Institute, it’s two to three times more common in Asian countries than anywhere else in the world.

Aplastic anemia occurs when the body’s bone marrow doesn’t make enough new blood cells. The rashes resemble patches of pinpoint red or purple spots, known as petechiae. These red spots may be raised or flat on the skin. They can appear anywhere on the body but are more common on the neck, arms, and legs.

The petechial red spots do not typically cause any symptoms like pain or itching. You should notice that they stay red, even if you press on the skin.

In aplastic anemia, not only is there a shortage of red blood cells, there is also a lower than normal level of platelets, another type of blood cell. Low platelet count tends to result in bruising or bleeding more easily. This leads to bruises that look like rashes.

Thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura is a rare blood disorder that causes tiny blood clots to form throughout your body. This can cause the tiny red or purple spots known as petechiae, as well as unexplained purplish bruising that can look like a rash. The bruising is known as purpura.

Paroxysmal nocturnal hemoglobinuria

Paroxysmal nocturnal hemoglobinuria is a very rare genetic disorder in which a genetic mutation causes your body to produce abnormal red blood cells that break down too quickly. This can cause blood clots and unexplained bruising.

Hemolytic uremic syndrome

Hemolytic uremic syndrome is a condition in which an immune reaction causes the destruction of red blood cells. The immune reaction can be triggered by bacterial infections, some medications, and even pregnancy. It can cause small, unexplained bruising and swelling, particularly of your face, hands, or feet.

Other causes

Iron deficiency anemia is one of the most common types of anemia. People with iron deficiency of any kind may develop pruritus, which is the medical term for itchy skin. As you itch, you may scratch your skin, which can cause redness and bumps that look like rashes.

In some cases, treatment for iron deficiency anemia may also cause rashes. Ferrous sulfate is a type of iron supplement that your doctor may prescribe to you if you have iron deficiency anemia. Some people may develop an allergy to the ferrous sulfate therapy. This can cause you to develop an itchy rash and hives. The hives or rash can appear anywhere on the body and may also come with some skin swelling under the red areas.

You should seek medical attention immediately if you think you have hives or an allergic rash due to ferrous sulfate, especially if you experience any swelling of the lips, tongue, or throat.

Your doctor may suspect anemia as the cause of your rash if it meets the physical description and is accompanied with other common anemia symptoms. These include:

• pale skin
• fatigue
• shortness of breath

Your doctor may check you for aplastic anemia if you display symptoms like:

• rapid or irregular heartbeat
• unexplained, easy bruising
• prolonged bleeding from cuts, especially minor ones
• dizziness and headaches
• nosebleeds
• bleeding gums
• frequent infections, especially those that take longer to clear up than normal

If you’re experiencing a rash or skin changes, you should make an appointment to see your doctor or dermatologist, especially if:

• the rash is severe and comes on suddenly with no explanation
• the rash covers your whole body
• the rash lasts more than two weeks and hasn’t improved with home treatment
• you also experience other symptoms like tiredness, fever, weight loss, or changes in bowel movements

If you believe that the rash is a reaction to new iron supplements that you’ve started taking, seek immediate medical attention. You could be having an allergic reaction or may be taking too high of a dose.

The best ways to treat anemia rashes is to treat the underlying conditions causing them. If your doctor suspects or diagnoses iron deficiency as a cause, they will likely have you start taking iron supplements.

Treating aplastic anemia is sometimes more difficult. Treatments used in aplastic anemia include:

Blood transfusions: Blood transfusions can reduce symptoms but not cure aplastic anemia. You may get a transfusion of both red blood cells and platelets. There isn’t a limit to the number of blood transfusions you can receive. However, they may become less effective over time as your body develops antibodies against transfused blood.

Immunosuppressant drugs: These medications suppress the damage that immune cells are doing to your bone marrow. This allows the bone marrow to recover and create more blood cells.

Stem cell transplants: These can help rebuild the bone marrow to the point where it creates enough blood cells.

Anemia can’t be prevented, so the best way to try to prevent anemia rashes is to treat the underlying causes. Make sure you’re getting enough iron through your diet or with supplements to prevent iron deficiency anemia and iron deficiency-related pruritus.

If you develop an unexplained rash, see your doctor right away. If you don’t already have a provider, our Healthline FindCare tool can help you connect to physicians in your area.

Keep reading: The top 10 foods high in iron »

Cryotherapy – Acne treatment, acne and pimple removal

Liquid nitrogen, cryotherapy, cryomassage

Liquid nitrogen for acne, pimples

Acne treatment in the Acne Clinic and skin rehabilitation is a complex technique. It includes cleansing the skin with a special treatment using liquid nitrogen, which fights the inflammatory process and leads to skin healing. Our task is to eliminate the cause of acne and cure its consequences. The clinic has specialized on treatment acne since 1993 years old The great experience of our doctors will allow us to achieve a positive effect in the treatment of acne in most cases.

What is liquid nitrogen acne treatment?

To understand how liquid nitrogen works for acne, you need to look inside the skin during the appearance of acne on the face. With acne, there is an inflammatory focus in the dermis, which provokes more and more acne. The use of only home remedies solves the problem superficially, so even if you have achieved improvement, this is usually a temporary result and acne is activated again and again.

What happens with liquid nitrogen acne treatment?

Liquid nitrogen acts on the skin with cold, while blocking nerve impulses. Due to this, peripheral blood supply is improved, metabolic processes are accelerated, which allows to resolve inflammatory infiltration in acne and normalize sebum secretion.
In the treatment of acne with nitrogen, the effect is not only on acne, but also on the focus of inflammation. Cold acts on skin formations, and you see how acne on the face decreases. And this is what you were aiming for.

Why do we choose liquid nitrogen for acne treatment?

The peculiarity of the treatment of acne with liquid nitrogen on the face is that it acts on all skin causes that lead to the appearance of acne. Local cryotherapy is an excellent tool for the prevention and treatment of complications after acne in the form of scars and spots. Liquid nitrogen treatment is very gentle, which is especially important for people with severe acne. All our patients after cryotherapy acquire clean and healthy skin.

Results of acne treatment with liquid nitrogen

Already after the first cryotherapy sessions, the skin condition improves. After the liquid nitrogen procedure, sebum secretion is significantly reduced, the face “comes to life” – it becomes fresh, inflammatory elements decrease.

Cryotherapy price

Liquid nitrogen for acne works independently, without requiring any equipment or expensive preparations to help. Cryotherapy treatment is an affordable and effective procedure. And the price-performance ratio will surprise you. Come visit us at the Clinic. Many of our patients have already got rid of acne, there is no more acne on their face, and there will be no acne.

Liquid nitrogen, cryotherapy in cosmetology

Cryomassage of the face with liquid nitrogen

Cryomassage of the face, cryotherapy of the face is the fastest and most comfortable cosmetic procedure. During the procedure, only a thin surface layer is cooled, so a slight cooling with liquid nitrogen is very pleasant for the patient.

10-15 minutes after the procedure, the patient feels a surge of warmth to the face – as if something had opened in the skin and it was breathing. Similar to chemical peeling, liquid nitrogen massage promotes exfoliation of the surface layers of the epidermis and the emergence of young healthy cells. But with cryomassage, this process is more physiological and gentle.

After cryomassage, the face becomes pink, as if glowing from the inside. In addition, liquid nitrogen remarkably cares for the skin and helps prevent its aging.

Indications for cryomassage, cryotherapy:

• reduced skin turgor and elasticity, first wrinkles;
• anemic skin with poor circulation;
• edema, pasty skin, including after cosmetic plastic surgery;
• seborrheic, porous, oily skin with increased sebum secretion;
• rosacea, acne vulgaris and comedones;
• preparation for cleaning, cosmetic massage, peeling of patients with problematic skin due to the powerful absorbable and anti-inflammatory action of nitrogen;
• combination of adult aging skin, prone to pimples, scars, along with a violation of its elasticity and the formation of wrinkles.

What does anemic mean – Meaning of words

Explanatory dictionary of the Russian language. S.I. Ozhegov, N.Yu. Shvedova.

anemic

th, th; -chen, -chen. Anaemic, and also generally pale and lethargic; expressing such a state. A. teenager. A. view.

n. anemic, and, well.

New explanatory and derivational dictionary of the Russian language, T. F. Efremova.

anemic

adj.

1. 1. Related by value with noun: anemia associated with it.

   2. open Painfully pale, weak.

2. rev. unfold Deprived of a lively interest in the environment; indifferent,
   indifferent.

Examples of the use of the word anemic in the literature.

Painful face, skin oily, shiny, sallow, yellowish, often anemic, covered with vesicular eruptions on the edge of the scalp, around the ears and on the back of the neck.

Fat, lethargic anemic patients, sometimes they can be called plump, the face is usually ruddy, they are completely unbearable, after any, even minimal physical effort, the patient may develop a fever or headache.

Returning to Greensboro was out of the question – after all, everyone understood that the anemic Bill Porter went to Texas not only to recover, but in search of fate.

Three anemic light bulbs, hanging on electric wires from the vaulted ceiling, barely illuminated a long dormitory with two rows of small wooden trestle beds along the walls on stone slabs of the floor.

It serves as a natural stimulus for the closure of the great blood sinuses, which makes the placental site anemic and hastens the discharge of the placenta.

Immersed in thoughts about his person and various comparisons, he came to the conclusion that he himself was becoming more and more feminine, and, as a result, finally falling in love with the circus performer, he began to dream about her, just as an anemic girl dreams of Hercules, capable of crushing her in his arms.

Lanky, lethargic, anemic, bewildered, Arnika stood with her arms dangling in the middle of a small class, and when Madame Semyon pointed out: “On the third bench from the left, Mademoiselle Petra,” the class broke out even more, despite any exhortations.

Even if Nietzsche and Kierkegaard had been born in the most anemic period of history, their inspiration would not have been any less nervous or less incendiary.

If such an anemic girl is not cured in time, if her reactivity is not increased, a serious illness may begin.

We know from trials, and also from various cases of illness, that when too much iron is given, the skin of a person becomes pale, takes on a greenish, waxy, yellowish tint, and the characteristic appearance of a sickly, anemic subject arises.

People who are accustomed to constantly drinking milk become anemic, they develop catarrhal conditions, fatty degeneration of the muscles, heart and liver.

She cut off a piece of anemic sausage, put a spittle of mashed potatoes with a knife, smeared it all with mustard and held the whole structure until it went into her mouth.

He was not at all surprised when Rem’s car stopped in front of his villa in Neubabelsberg and the stormtrooper headquarters, puffing and puffing, as if the anemic heat of Berlin June was a tropical heat, ascended the steps of the balcony.