Venous Eczema (Stasis Dermatitis)

Introduction | Aetiology and Risk Factors | Clinical Presentation | Diagnosis | Management and Treatment | Prevention | When to Refer | References

Introduction

Venous eczema, also known as stasis dermatitis, is a chronic inflammatory skin condition that typically affects the lower legs. It is associated with chronic venous insufficiency, where impaired blood flow in the veins leads to increased pressure, fluid leakage, and subsequent skin changes. Venous eczema is characterised by itching, redness, scaling, and skin thickening, and can be complicated by ulcers or secondary infections if not properly managed.

Aetiology and Risk Factors

Venous eczema is primarily caused by underlying venous insufficiency, but several factors contribute to its development:

• Chronic Venous Insufficiency: The primary cause of venous eczema, this condition occurs when the valves in the leg veins do not function properly, leading to blood pooling and increased pressure in the lower extremities.
• Age: Venous eczema is more common in older adults due to the weakening of vein walls and valves with age.
• Obesity: Excess weight increases the pressure on leg veins, contributing to venous insufficiency and the development of venous eczema.
• Prolonged Standing or Sitting: Occupations or lifestyles that involve long periods of standing or sitting can impede blood flow, increasing the risk of venous eczema.
• Previous Leg Injuries or Surgeries: Injuries or surgeries that affect the veins can lead to venous insufficiency and subsequent eczema.
• Deep Vein Thrombosis (DVT): A history of DVT can damage the valves in the veins, leading to venous insufficiency and venous eczema.

Clinical Presentation

Venous eczema typically presents with the following features:

• Itching and Discomfort: Persistent itching is a common symptom, often leading to scratching that can exacerbate the condition.
• Redness and Inflammation: The skin appears red and inflamed, particularly around the ankles and lower legs.
• Scaling and Crusting: The affected skin may become scaly, crusted, or develop a leathery texture (lichenification) due to chronic scratching and inflammation.
• Swelling (Oedema): Swelling in the lower legs is common, especially after prolonged standing or at the end of the day.
• Brown Discolouration: Chronic venous insufficiency can lead to hemosiderin deposition in the skin, resulting in brownish discolouration (hyperpigmentation).
• Weeping and Oozing: In more severe cases, the skin may ooze clear fluid, leading to crusting and an increased risk of secondary infection.
• Varicose Veins: Prominent, twisted veins may be visible on the legs, indicating underlying venous insufficiency.
• Ulceration: If left untreated, venous eczema can lead to the development of venous ulcers, particularly around the ankles.

Diagnosis

The diagnosis of venous eczema is primarily clinical, based on the characteristic appearance of the skin and the presence of underlying venous insufficiency:

• History: Take a detailed history, including symptoms of itching, swelling, and discomfort, as well as any history of varicose veins, DVT, or leg injuries.
• Physical Examination: Examine the lower legs for signs of eczema, varicose veins, oedema, and skin changes such as hyperpigmentation or ulceration.
• Doppler Ultrasound: A Doppler ultrasound may be performed to assess venous function and confirm the presence of venous insufficiency.
• Differential Diagnosis: Consider other conditions that may present similarly, such as cellulitis, contact dermatitis, or atopic dermatitis.
• Patch Testing: In cases where contact dermatitis is suspected, patch testing may be performed to identify potential allergens.

Management and Treatment

Management of venous eczema focuses on treating the underlying venous insufficiency, reducing inflammation, and preventing complications:

1. Compression Therapy

• Compression Stockings: Compression stockings are the cornerstone of treatment for venous eczema, as they help improve venous return, reduce swelling, and prevent the progression of skin changes. Patients should be fitted with appropriate compression levels based on the severity of their condition.
• Leg Elevation: Elevating the legs above heart level several times a day can help reduce oedema and improve circulation.

2. Topical Treatments

• Topical Corticosteroids: Topical steroids are used to reduce inflammation and itching. The choice of potency depends on the severity and location of the eczema:
  • Hydrocortisone 1%: A mild steroid suitable for mild cases or sensitive areas.
  • Betamethasone valerate 0.1%: A more potent steroid used for moderate to severe eczema on thicker skin areas.
• Emollients: Regular use of emollients is essential to maintain skin hydration, reduce scaling, and prevent flare-ups. Fragrance-free, hypoallergenic emollients are recommended.
• Antibiotic Creams: If secondary bacterial infection is present, topical antibiotics like fusidic acid or mupirocin may be prescribed.
• Topical Calcineurin Inhibitors: Tacrolimus or pimecrolimus may be considered as steroid-sparing agents, particularly for long-term management.

3. Oral Treatments

• Oral Antibiotics: In cases of secondary infection, oral antibiotics such as flucloxacillin may be required.
• Oral Antihistamines: These can help control itching, especially if it interferes with sleep. Non-sedating antihistamines like cetirizine or loratadine are preferred during the day.

4. Lifestyle and Supportive Care

• Skin Care Routine: Advise patients to use gentle, fragrance-free products and avoid hot water, which can further dry out the skin.
• Weight Management: Encourage weight loss in overweight patients to reduce the pressure on the leg veins and improve venous return.
• Exercise: Regular physical activity, particularly walking, can help improve circulation and reduce the risk of venous insufficiency worsening.

5. Treatment of Underlying Venous Insufficiency

• Endovenous Ablation: In some cases, treating the underlying venous insufficiency with procedures such as endovenous laser ablation or radiofrequency ablation may be necessary to prevent recurrence of venous eczema.
• Sclerotherapy: This procedure involves injecting a solution into varicose veins to close them off, which can help reduce symptoms of venous insufficiency.
• Surgery: In severe cases, surgical intervention may be required to correct underlying venous problems.

Prevention

Preventive measures are crucial in managing venous eczema and reducing the risk of complications:

• Compression Stockings: Regular use of compression stockings can prevent the progression of venous insufficiency and associated skin changes.
• Leg Elevation: Elevating the legs regularly can help prevent swelling and improve circulation.
• Skin Care: Maintaining good skin care with regular use of emollients can prevent dryness and reduce the risk of eczema flare-ups.
• Avoid Prolonged Standing or Sitting: Encourage patients to move regularly, especially if they have jobs that require prolonged standing or sitting.

When to Refer

Referral to a specialist may be necessary in the following situations:

• Severe or Refractory Cases: If venous eczema does not respond to standard treatments or if the condition is severe, referral to a dermatologist or vascular specialist is advised.
• Complications: If there are complications such as venous ulcers, cellulitis, or persistent swelling, specialist input is required for further management.
• Consideration for Surgical Intervention: Referral to a vascular surgeon may be necessary if surgical treatment of the underlying venous insufficiency is indicated.

References

1. British Association of Dermatologists (2024) Guidelines for the Management of Venous Eczema. Available at: https://www.bad.org.uk (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Venous Eczema: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng103 (Accessed: 26 August 2024).
3. British National Formulary (2024) Topical and Oral Treatments for Dermatological Conditions. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).