Venous Eczema

Venous eczema (stasis dermatitis) is an inflammatory dermatosis of the lower legs caused by chronic venous hypertension from valvular incompetence or obstruction. Capillary leak, haemosiderin deposition and local inflammation drive the skin changes.

• Risk factors: varicose veins, previous deep vein thrombosis, obesity, pregnancies, prolonged standing, leg injury, heart failure, immobility.
• Later stages progress to lipodermatosclerosis and venous ulceration.

Itchy, scaly, erythematous or weeping patches over the medial malleolus and gaiter area, with brown haemosiderin pigmentation, oedema, and varicosities.

• Chronic stage: skin induration, inverted champagne bottle leg (lipodermatosclerosis), atrophie blanche.
• Differential diagnosis: cellulitis, contact dermatitis (topical antibiotics, lanolin, neomycin), asteatotic eczema, nummular eczema, pretibial myxoedema, Kaposi sarcoma, necrobiosis lipoidica, peripheral arterial disease, heart failure oedema, vasculitis.
• Complications: venous ulcer, secondary infection and cellulitis, contact sensitisation, autoeczematisation (id reaction), bleeding from varicosities, chronic pain.

Clinical, with vascular assessment.

• Ankle brachial pressure index (to exclude arterial disease before compression); venous duplex ultrasound for reflux and obstruction.
• Swab if weeping or crusted; glucose, renal function, albumin, full blood count, heart failure assessment.
• Patch testing in non responders to exclude contact allergy.

Compression and treatment of the venous disease are essential.

• Supportive: leg elevation above heart level for 30 minutes three to four times daily, exercise and calf muscle pump activation, weight loss, skin care with soap substitute and greasy emollient ointment, avoid scratching and sensitisers (neomycin, lanolin, fragrance, topical antibiotics).
• Pharmacological: mometasone furoate 0.1 percent ointment or betamethasone valerate 0.1 percent ointment once daily for 2 weeks, then taper to twice weekly; flucloxacillin 500 mg four times daily for 7 days for secondary infection (clindamycin 300 mg four times daily if penicillin allergic); non sedating antihistamines are of limited help for itch. Pentoxifylline 400 mg three times daily as adjunct in ulceration.
• Procedures: compression bandaging or stockings at 30 to 40 mmHg after an ankle brachial index of 0.8 or more; endovenous ablation, sclerotherapy or surgery for symptomatic reflux.
• Special groups: pregnancy, compression stockings and elevation, mild to moderate steroids; elderly, protect thin skin and check ankle brachial index; diabetes, check feet and neuropathy; heart failure, avoid compression until compensated.
• Red flags: ankle brachial index below 0.8 (reduced compression), spreading cellulitis, ulceration, fever, unilateral sudden swelling (deep vein thrombosis), non healing sore.
• Follow-up: review at 2 weeks; lifelong compression and skin care; refer for venous intervention and ulcer care.