Stasis Dermatitis
Basics
- Chronic eczematous, scaling, erythematous plaques/patches on lower legs.
- Associated with chronic venous insufficiency (valve dysfunction/reflux or vein obstruction).
- Typical location: medial ankle, can extend to foot and lower leg.
- May present as solitary lesion; often bilateral.
- Can be accompanied by venous leg ulcers on bony prominences.
Epidemiology
- Common in patients >50 years (6-7% incidence in the US).
- Female predominance.
- Estimated 15-20 million affected in US aged >50.
Etiology and Pathophysiology
- Venous hypertension from venous valve incompetence or obstruction.
- Microvascular changes: leaking capillaries, fibrin cuffs, thickened venules, microthrombosis.
- Chronic dependent edema inflames skin, predisposing to trauma and pruritus.
- Itch mediated by inflammatory cells and endothelial dysfunction.
- Familial predisposition likely.
Risk Factors
- Atopy, chronic edema.
- Old age, obesity.
- Smoking.
- Previous DVT, pregnancy, vein stripping/harvesting.
- Prolonged standing.
- Trauma.
- Low-protein diet.
- High estrogen states.
- Genetic/familial congenital vein disease.
General Prevention
- Treat edema via leg elevation, compression stockings, exercise.
- Early venous insufficiency management by specialists.
- Use emollients twice daily to prevent fissures and itching.
Commonly Associated Conditions
- Varicose veins, venous insufficiency.
- Hyperhomocysteinemia.
- Venous hypertension.
Diagnosis
History
- Itching, pain, burning precede rash.
- Bilateral lower extremity edema and aching/heaviness.
- Erythema and scaling with hyperpigmentation.
- Symptoms worsen with prolonged dependency.
Physical Exam
- Bilateral scaly, eczematous patches, papules, plaques.
- Violaceous/brown erythema from hemosiderin.
- Medial ankle distribution, possible foot/lateral ankle extension.
- Superficial veins visible, pitting edema.
- Brawny induration, warmth.
- Venous ulcers over bony prominences.
- Later excoriations, weeping, crusting.
- Possible comorbid atrophie blanche, lipodermatosclerosis.
- Contact sensitization and autosensitization dermatitis possible.
Differential Diagnosis
- Atopic, uremic, contact dermatitis.
- Neurodermatitis.
- Arterial insufficiency.
- Sickle cell ulcers.
- Cellulitis, erysipelas.
- Tinea, pretibial myxedema.
- Nummular eczema.
- Lichen simplex chronicus.
- Xerosis, asteatotic eczema.
- Amyopathic dermatomyositis.
- Psoriasis.
- Actinic keratoses.
- Skin cancers.
Diagnostic Tests
- Duplex ultrasound: confirms venous insufficiency (reflux duration >0.5 sec superficial/perforating veins, >1 sec deep veins).
- Cross-sectional venography (CT/MR) if ultrasound equivocal.
- Skin biopsy for uncertain cases (cautiously due to arterial insufficiency risk).
- Rule out arterial insufficiency: check pulses, ankle-brachial index (ABI).
- Screen for diabetes.
- Catheter venography before interventions.
Treatment
General Measures
- Reverse venous hypertension:
- Leg elevation (30 min, 3-4 times daily).
- Compression therapy (bandages, stockings) if ABI 0.8-1.2.
- Graduated compression (30-40 mm Hg) improves healing/prevents ulcers.
- Pneumatic compression devices for nonambulatory or mixed arterial cases.
- Encourage regular exercise, avoid prolonged standing.
- Inpatient/endovascular interventions for severe cases (radiofrequency ablation, vein stripping, sclerotherapy, skin grafts).
- Venous ulcer care:
- Debride necrotic tissue.
- Use moist wound dressings (hydrogel, hydrocolloid, foam).
- Granulocyte-macrophage colony-stimulating factor may aid healing.
- Surgical correction of venous hypertension if indicated.
Medication
- Pentoxifylline 400 mg TID: effective for venous leg ulcers.
- Antibiotics only for clinical infection (cellulitis, pain, malodor).
- Oral antibiotics for secondary infections: dicloxacillin, cephalexin, levofloxacin.
- MRSA: clindamycin, doxycycline, TMP/SMX, vancomycin.
- No evidence for routine antiseptics.
- Short courses topical steroids (triamcinolone 0.1% BID) for dermatitis.
- Topical antipruritics: pramoxine, camphor, menthol, doxepin.
- Lidocaine/prilocaine for pain during debridement.
- Silver sulfadiazine for wound healing.
- Topical emollients and antihistamines (diphenhydramine, cetirizine) for chronic cases.
- Hydrocolloid or foam dressings may reduce pain.
Second Line
- Antibiotics guided by culture.
- Lubricants for quiescent dermatitis.
Issues for Referral
- Nonhealing ulcers.
- Arterial insufficiency.
- Patch testing for contact dermatitis.
- Varicose veins and venous insufficiency.
Additional Therapies
- Discontinue meds causing edema if possible (amlodipine, gabapentin).
Surgery/Other Procedures
- Sclerotherapy, ablation, vein stripping, skin grafting for venous disease.
Ongoing Care
Follow-up
- Reapply Unna boots weekly.
- Regular compression stockings use to prevent ulcer recurrence.
Diet
- Weight loss if overweight.
Patient Education
- Encourage activity and leg elevation.
- Avoid constrictive garments.
- Apply compression stockings before getting up.
- Do not scratch affected areas.
Prognosis
- Chronic intermittent exacerbations/remissions.
- Ulcer healing prolonged (months).
- Quality of life impacted by itching, pain, burning.
Complications
- Secondary bacterial infection.
- Contact sensitization/auto-sensitization dermatitis.
- Bleeding from dermatitis sites.
- Squamous cell carcinoma at long-standing ulcer edges.
- Scarring compromising circulation.
ICD10 Codes:
- I83.10 Varicose veins of unspecified lower extremity with inflammation
- I83.11 Varicose veins of right lower extremity with inflammation
- I83.12 Varicose veins of left lower extremity with inflammation
Clinical Pearls:
- Edema treatment via elevation, exercise, compression essential.
- Hydrocolloid vs nonadherent dressing under compression shows no difference in healing rate.
- Dressing choice should consider cost and preference.