Varicose Eczema

Synonyms: gravitational eczema, stasis eczema, venous eczema.

These terms describe the skin changes which occur as a result of an increase in venous pressure in the legs. The venous pressure is increased usually because of incompetent valves in the deep or superficial veins, or because of thrombosis in deep veins causing obstruction to venous flow (with or without valve damage).

The exact pathophysiology behind the skin changes is unclear. Leakage of blood constituents into the surrounding tissues and activation of inflammatory cells and fibroblasts is broadly responsible for the changes observed.
These skin changes progress through the following changes:

• Mild pigmentation from haemosiderin deposition
• Areas of inflammatory change and eczema
• Fibrosis and atrophic changes in the skin (lipodermatosclerosis or atrophie blanche)
• Ulceration of the skin¹

Subsequently contact allergic dermatitis may result from preservatives such as parabens, lanolin, rubber in bandages, or antibiotics used in dressings.

Varicose eczema is a common problem particularly in the elderly. The chronic nature of varicose eczema and the requirement for regular treatment mean that it can carry significant morbidity and have major socioeconomic implications. Some perspective on the scale of the problem can be appreciated from the following:

• The prevalence of skin changes including hyperpigmentation and eczema due to chronic venous insufficiency varies between 3% and 11% of the population.²
• Varicose veins are present in 25% to 33% of female and 10% to 20% of male adults. The incidence of varicose veins is 2.6% per year in women and 1.9% per year in men.²
• Venous ulcers occur in about 0.3% of the adult population.²

History

It is important to find out whether venous hypertension is likely, as this supports a diagnosis of venous skin problems. Indicators of possible venous hypertension include:

• Varicose veins. However severe venous hypertension can occur in the absence of visible varicose veins.
• Varicose vein surgery.
• A past history of deep vein thrombosis, or leg ulcers.

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

Examination

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).
Look specifically for:

• Varicose veins. Note the location and severity of any varicose veins. They may not be apparent until the patient stands.
• Skin changes- nature and severity. Look for:
  • The red, scaly or flaky skin of venous eczema. There may also be blisters and crusts on the surface.
  • Lipodermatosclerosis:
    • Hardened, tight, red or brown skin.
    • Usually affecting the inner aspect of the calf.
    • The subcutaneous tissues may become hard and depressed ('inverted champagne bottle' leg if the damage is circumferential).
    • It can present acutely and be wrongly diagnosed as cellulitis (or phlebitis).³
  • Atrophie blanche:
    • Star-shaped, white (ivory), depressed, and atrophic scars surrounded by pigmentation.
    • Frequently found where an ulcer has healed.
  • Venous ulceration.¹
• Examine foot pulses.
• Consider measuring the ankle-brachial pressure index using a Doppler machine if use of compression stockings is being considered.
  Some experts consider this unnecessary if the foot pulses are easily palpable, and the person has no symptoms of arterial disease.⁴
• The classic tourniquet tests provide some information about the sites of deep-to-superficial reflux. However they are difficult to interpret if varicose veins are not prominent and offer little information about the deep veins. They have been complemented by hand-held continuous-wave Doppler. This can reveal that many "recurrent" varicose veins actually result from previously unsuspected incompetent perforating veins or reflux in the short saphenous vein.

• Varicose eczema is a consequence of increased venous pressure and venous insufficiency in the legs.
• The history and clinical examination will not always indicate the nature and extent of the underlying abnormality.
• There are now a multitude of diagnostic tests to evaluate the anatomic extent, pathology, and cause of the venous insufficiency.
  These require careful interpretation and detail on these is beyond the scope of this article. The scope of these tests can be appreciated from the consensus paper on the use of these tests.²Broadly speaking they can be used to evaluate any calf muscle pump dysfunction and to determine the anatomic extent and severity of any venous obstruction or reflux.

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.

• General advice:
  • Avoid injury to the skin (e.g. against furniture). This may very easily lead to ulceration.
  • Elevate the legs when resting (e.g. whenever sitting).
  • Keep physically active. Encourage regular walks.
• Basic skin care:
  • Advise regular use of emollient.
  • Treat symptom flares with a topical steroid (usually moderate strength).The skin is usually dry and may be ulcerated and so an ointment may be preferable to a cream.
  • Try to avoid potential skin sensitisers during management.⁵ Emollients are safe and effective. If people wish to use herbal remedies, they are probably more likely to cause allergy.
• Below knee compression hosiery:
  • Provided that there is no arterial insufficiency, below-knee compression stockings should be worn. In older people, Doppler testing may be required to ascertain arterial competence first.⁶ Although they are of proven efficacy, patients are often reluctant to wear them as they are rather uncomfortable.⁷ Stockings come in 3 grades of pressure:
    • Class 2 (medium) stockings are suitable for most people.
    • Class 1 (light) stocking if the person cannot tolerate a class 2 stocking.
    • Class 3 (strong) stockings may be necessary if the response to a class 2 stocking is inadequate (however many people find these difficult to tolerate).
  • For detailed information on the prescribing and use of compression stockings, see the CKS topic on Compression stockings.⁴
• If poor response to the above then consider:
  • Contact dermatitis (for example to applied topical treatments or materials in compression stockings).
  • Flares of lipodermatosclerosis may require application of very potent topical steroids.
  • Secondary infection. This may need treatment. Oral antibiotics reduce the risk of allergy.
• Know when to refer (see below).

This is a condition which is likely to require involvement of different disciplines. Do not be reluctant to use the expertise of other members of the primary health care team.

• Refer according to any local policies.
• When there are no local policies consider referral when:
  • Varicose veins present with progressive skin changes or a history of ulceration. Referral usually to a vascular surgeon.
  • There is significant arterial insufficiency (Doppler shows ankle-brachial pressure index of less than 0.8). Again referral to a vascular surgeon is recommended.
  • There is inadequate control of skin disease with primary care management above. Referral to a dermatologist is recommended.
  • There is suspected contact dermatitis. 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 refer the patient to a dermatologist for further management and patch testing.
  • When considering referral, take into account general state of health and comorbidities.

• 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.

There may be scope for prevention of skin disease and other complications with:

• Better management of varicose veins
• Better management of venous insufficiency
• Prevention of deep vein thrombosis (surgery, flights etc)
• Better detection and management of deep vein thrombosis

All of this might be achieved with good primary care and timely referral to the appropriate specialist.