Varicose Eczema

This is also known as gravitational eczema and stasis eczema.

Varicose eczema is the result of venous hypertension. This is usually due to varicose veins but can follow deep vein thrombosis.

There is poorly defined scaling and erythema around the ankle. There are often pigmentary changes, both post-inflammatory (dirty brown colour) and haemosiderin (rusty brown), as well as other secondary changes of venous disease such as dilated venules, varicose veins, sometimes oedema and frank ulceration.

Varicose veins are to be expected but they may not be apparent until the patient stands.

Occasionally varicose eczema may become generalised, but there should be a history of initial eczema around the ankle.

The appearance is fairly characteristic but the distribution is also important. It will start over or just above the malleoli. It may look like cellulitis but the latter will be hot and shiny and without scaling on the surface. Erythema and dryness of the skin are the major signs to look for. Small blisters (vesicles) are common in eczema. These break down and the serous fluid released dries to form crusts which coalesce. Although blister formation is uncommon in cellulitis, if blisters do develop they are large and herald the onset of skin necrosis.

Varicose eczema is usually bilateral and will have secondary changes present too. The pigmentary changes are typical. There is often dependent oedema. Check for varicose veins.

The underlying pathology is prolonged venous hypertension in the skin of the lower legs. Blood leaks out into the tissues and causes the pigmentary changes, including deposition of haemosiderin. Contact allergic dermatitis may result from preservatives such as parabens, lanolin, rubber in bandages, or antibiotics used in dressings.

• A moderately potent steroid application should help the eczema. The skin is usually dry and may be ulcerated and so an ointment may be preferable to a cream.
• Provided that there is no arterial insufficiency, support stocking should be worn. In older people, Doppler testing may be required to ascertain arterial competence first.¹ Stockings come in 3 grades of pressure. Although they are of proven efficacy, patients are often reluctant to wear them as they are rather uncomfortable.²
• Energetic treatment is important to prevent ulcers from appearing but this is a chronic condition and treatment takes a long time.
• If ulceration occurs, the district or practice nurse will become involved and a multidisciplinary approach is required.
• Try to avoid potential skin sensitisers during management.³ Emollients are safe and effective. If people wish to use herbal remedies, they are probably more likely to cause allergy.
• Secondary infection may need treatment. Oral antibiotics reduce the risk of allergy.
• Encourage regular walks and when sitting to elevate the leg to reduce oedema.
• Bearing in mind the aetiology, it may be appropriate to refer the patient for treatment of the varicose veins.

• This is a chronic condition and takes a long time to heal.
• Topical steroids will clear the eczema but the secondary pigmentary changes will persistent.
• Poor compliance with support hosiery or bandages makes prognosis worse than it should be.
• If ulceration occurs, it will be a slower resolution.
• This often occurs in old people with arterial insufficiency and hence poor healing.

Contact allergic dermatitis to paste bandages and medicaments applied to leg ulcers is common. If suspected either because the eczema does not heal up or has recently flared, send the patient to a dermatologist for patch testing.

Do not be reluctant to use the expertise of other members of the primary healthcare team.