Plate 14
Stasis Dermatitis
Also called: Venous eczema · Venous stasis dermatitis · Gravitational eczema
Eczema & dermatitisClinical photographs
5 photographs · shown uncropped
-
Stasis dermatitis : Bilateral diffuse erythema of the lower legs with marked edema, predominantly involving the distal extremities. Source : © DermNet New Zealand. Venous eczema. https://dermnetnz.org/topics/venous-eczema -
Ill-defined, confluent erythematous scaly plaques over the distal lower leg, with prominent whitish scale, superficial erosions, and scattered crusts on a background of brown hyperpigmentation. Source : © DermNet New Zealand. Venous eczema. https://dermnetnz.org/topics/venous-eczema -
Diffuse erythema of the prominently affected leg, with fine scaling and scattered superficial erosions and crusts, including a focal yellowish crust. Less pronounced involvement of the visible contralateral leg. Source : © DermNet New Zealand. Venous eczema. https://dermnetnz.org/topics/venous-eczema -
Extensive confluent erythematous plaque involving the distal lower leg and perimalleolar region, with a partly shiny surface, peeling scale, and scattered pinpoint crusted erosions. Source : © DermNet New Zealand. Venous eczema. https://dermnetnz.org/topics/venous-eczema -
Irregular reddish-brown macules and patches over the distal lower leg, becoming confluent in places, with fine scaling and a more prominent erythematous patch near the ankle. Source : © DermNet New Zealand. Venous eczema. https://dermnetnz.org/topics/venous-eczema
Clinical images provided for educational purposes.
General information
- Chronic inflammatory dermatosis of the lower extremities secondary to chronic venous insufficiency and venous hypertension
- Venous hypertension leads to extravasation of fluid, proteins, and red blood cells into the tissues, contributing to edema, inflammation, and hemosiderin deposition
- More common in older adults > 50 years of age
- Risk factors include chronic venous insufficiency, varicose veins, previous DVT, obesity, pregnancy, prolonged immobility, and older age
Symptoms / presentation
- Chronic pruritus of the lower legs
- Sensation of heavy or uncomfortable legs
- Ankle edema, typically worse after prolonged standing and toward the end of the day
- History of varicose veins, deep vein thrombosis, or venous ulcers may be present
- Recurrent episodes of lower-leg eczema
- Significant pain, warmth, rapid progression, fever, or purulent drainage should raise concern for secondary infection or another diagnosis
Clinical exam
- Poorly demarcated erythematous to reddish-brown patches and plaques
- Fine scaling with possible oozing and crusting during acute eczematous flares
- Pitting edema, particularly around the ankles
- Varicose veins and telangiectasias may be present
- Lipodermatosclerosis: induration and fibrosis of the lower leg in which advanced disease may produce an “inverted champagne bottle” appearance
- Small, atrophic, porcelain-white scar-like areas may be present
- Venous ulcers may develop in advanced disease, classically around the medial malleolus
Distribution
- Lower legs +++
- Malleolar region
- Ankles
- May extend onto the dorsum of the foot
- Usually bilateral, although may be asymmetric
Dermoscopy
- Dermoscopy is mainly complementary and not required for diagnosis
- Erythematous to brown background
- Diffuse orange-brown pigmentation corresponding to hemosiderin deposition
- Variable superficial scaling
Diagnosis
- Primarily a clinical diagnosis based on characteristic skin findings and evidence of chronic venous disease
- Venous duplex ultrasound if venous insufficiency has not been documented
- Ankle-brachial index (ABI) before compression therapy when peripheral arterial disease is suspected
- Bacterial culture only when there are clinical signs of infection
- Skin biopsy may be considered for atypical presentations
Differential diagnosis
- Bacterial cellulitis
- Allergic or irritant contact dermatitis
- Cutaneous vasculitis
- Lymphedema
- Pretibial myxedema
- Acute lipodermatosclerosis
Treatment plan
- Main goal: control venous hypertension and treat cutaneous inflammation
- Compression therapy = cornerstone of treatment when arterial circulation is adequate
- Regular leg elevation to reduce edema
- Encourage regular walking and physical activity
- Avoid prolonged standing or sitting
- Apply emollients daily to treat xerosis
- Eczematous flares: medium-potency topical corticosteroid, with a more potent agent occasionally used for a short course depending on severity and location
- Ex: triamcinolone 0.1% once or twice daily for 1-2 weeks
- Antibiotics only for true infection; colonization of a venous ulcer alone does not warrant systemic antibiotics
References
- • DermNet. Venous eczema, gravitational eczema
- • American Academy of Dermatology (AAD). Stasis dermatitis
- • UpToDate. Stasis dermatitis
- • Bolognia JL, Schaffer JV, Duncan KO, Ko CJ. Dermatology Essentials. Elsevier
- • Wolff K, Johnson RA, Suurmond D. Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology. McGraw-Hill
- • Yosipovitch G, Nedorost ST, Silverberg JI, et al. Stasis Dermatitis: An Overview of Its Clinical Presentation, Pathogenesis, and Management. Am J Clin Dermatol. 2023;24(2):275-286