In the United States, venous stasis dermatitis occurs in 6-7 percent of those over age 50, which translates to about 15-20 million people afflicted. The risk of developing stasis dermatitis increases with age and women are slightly more likely to be affected. Other risk factors include the presence of varicose veins, phlebitis, hypertension, obesity, congestive heart failure and renal failure.

Eczematous changes with redness, scaling and pruritus may be limited to a small patch on one leg or may involve the entire skin of both legs. The medial ankle skin is often the first to show changes, which may gradually encircle the lower leg and extend up to the knee. In severe cases of stasis dermatitis, the skin breaks down with oozing, crusted areas and ulceration. White, shiny scars are often left after healing.

Subcutaneous involvement of the fat, also known as lipodermatosclerosis, can accompany the eczematous changes in chronic cases. In these cases, the skin may appear shiny and atrophic or have reddish brown patches or a generalized darkening and thickening of the skin in the gaiter area. Edema is usually present. In such predisposed legs, cellulitis can occur due to fissures in the skin underlying the dermatitis or in persons with coexisting dermatophyte fungal infection of the feet.

Until the advent of outpatient endovenous ablative techniques, venous stasis dermatitis could only be managed with topical corticosteroid creams, compression hose and leg elevation. These interventions are still useful; however, the most important step in the treatment of stasis dermatitis is correction of the underlying venous hypertension.

Evaluation of lower extremity eczema should include a complete history and physical evaluation and duplex ultrasound mapping of the saphenous system and deep veins. In addition, allergy patch testing and a skin biopsy may prove useful in difficult cases.

Report of Two Cases

•    Case 1: DC, a 75 year old man presented with sudden onset of dermatitis on his right medial ankle and calf. He was prescribed a regimen of soap avoidance and mosturization, leg elevation, compression hose and topical 1 percent HC cream bid. Despite this regimen, the eruption failed to respond and he was prescribed topical triamcinolone ointment, 0.1 percent bid for the rash. Although he had some relief of pruritus when using the triamcinolone, the rash failed to clear. Duplex ultrasound scanning of the leg revealed GSV, SSV and Giacomini vein incompetence in that leg. Endovenous laser ablation of all the incompetent veins was performed. Within one week, the dermatitis had resolved with only hemosiderin staining of the affected skin which resolved within two months without the further use of topical corticosteroids. His skin has remained normal in more than two years.

•    Case 2: MS, a 64 year old woman presented with a two-year history of severe, pruritic dermatitis on the anterior left shin, unresponsive to topical triamcinolone ointment, soap avoidance and mosturization, leg elevation, and compression hose. She also related a history of a chronic skin ulcer above the left medial malleolus, which finally healed after six months. Examination of that area revealed skin hyperpigmentation, thickening and several white scars. Duplex ultrasound scanning of the leg revealed GSV, SSV and a Cockett’s perforator reflux. Endovenous laser ablation of all these veins was performed followed by foam sclerotherapy of a large cluster of tributary veins on the medial ankle. The dermatitis had completely resolved by the second week post laser surgery with hemosiderin staining of the affected skin. She remains asymptomatic three months after the procedures (See Figure 1).

Although the typical presentation of stasis dermatitis is on the medial ankle as in Case 1, Case 2 demonstrates that the dermatitis can appear anywhere on the leg, and a venous etiology should be sought by duplex ultrasound scanning whenever an isolated dermatitis on the legs is seen. Many times these cases are misdiagnosed and treated as nummular eczema for years with topical corticosteroid therapy, resulting in steroid atrophy of the skin with episodic outbreaks of the dermatitis.

Case 2 demonstrates the frequent association of venous stasis dermatitis with venous ulcers. In this case, the ulcer was on the same leg but not located within the eczematous area. Duplex ultrasound scanning revealed the presence of a perforator underlying the healed ulcer. Saphenous disease and perforator reflux must both be treated to achieve a long term cure of skin ulceration.

While topical corticosteroid creams, compression hose and leg elevation are elements of the treatment of venous stasis dermatitis, they address only half the problem: the skin. The underlying venous disease must be treated as well to cure longstanding dermatitis or prevent the progression of to skin ulceration.
In our hands, EVLA has resulted in the rapid resolution of dermatitis in both these cases, obviating the need for long term care with chronic topical corticosteroid therapy.

Robin M. Fleck, MD, FACP, FAAD, is founder and president of Vein Specialties LLC and Body Oasis Laser Cosmetic Solutions both in Prescott, Ariz. Dr. Fleck is a member of the ACP, Venous Forum and ASLMS.