Dermatitis, Stasis

para>Prevalence

Common in this age group:
- Estimated to affect 15 to 20 million patients age >50 years in the United States

ETIOLOGY AND PATHOPHYSIOLOGY

Incompetence of perforating veins causing blood to backflow to the superficial venous system leading to venous hypertension (HTN) and cutaneous inflammation
Deposition of fibrin around capillaries
Microvascular abnormalities
Ischemia
Continuous presence of edema in ankles, usually present because of venous valve incompetency (varicose veins)
Weakness of venous walls in lower extremities
Trauma to edematous, ischemic skin
Itch may be caused by inflammatory mediators (from mast cells, monocytes, macrophages, or neutrophils) liberated in the microcirculation and endothelium.
Abnormal leukocyte-endothelium interaction is proposed to be a major factor.
A cascade of biochemical events leads to ulceration.

Genetics
Familial link probable

RISK FACTORS

Previous deep venous thrombosis
Chronic edema (due to CHF, pulmonary HTN, obstructive sleep apnea; cirrhosis, nephrotic syndrome, or medication)
Previous pregnancy
Obesity
Atopy
Superimposed itch scratch cycle
Trauma
Genetic propensity
Prolonged medical illness
Secondary infection
Low-protein diet
Old age
Tight garments that constrict the thigh
Vein stripping
Vein harvesting for coronary artery bypass graft surgery
Previous cellulitis

GENERAL PREVENTION

Use compression stockings to avoid recurrence of edema and to mobilize the interstitial lymphatic fluid from the region of stasis dermatitis and also following DVT.
Topical lubricants twice a day to prevent fissuring and itching

COMMONLY ASSOCIATED CONDITIONS

Varicose veins
Venous insufficiency
Other eczematous disease
Hyperhomocysteinemia
Venous HTN
Most diseases that worsen peripheral edema (e.g. CHF, diastolic dysfunction)

DIAGNOSIS

HISTORY

Older than 50 years with exception of acquired venous insufficiency due to surgery, trauma, or thrombosis (1)
Pruritus, pain, and burning may precede skin signs, which are aggravated during evening hours.
Insidious onset (2)
Usually bilateral (3)
Reddish-brown skin discoloration (3)
Edema-initially develops around the ankle (3)
Trauma is more indicative of cellulitis (3).

PHYSICAL EXAM

Evaluation of the lower extremities characteristically reveals:
- Bilateral, pitting edema (4,5)
- Typically with erythema, hyperpigmentation-more common in the lower 1/3 of the extremity and medially (4,5)
Violaceous (sometimes brown), erythematous-colored lesions due to deoxygenation of venous blood (postinflammatory hyperpigmentation and hemosiderin deposition within the cutaneous tissue)
- Serous drainage, weeping, crusting, inflammation of the skin
- Superficial desquamation (4)
- May present as a solitary lesion mimicking a neoplasm (6)

DIFFERENTIAL DIAGNOSIS

Cellulitis or erysipelas
Trauma-related inflammation
Deep vein thrombosis
Nonspecific dermatitis
Thrombophlebitis
Contact dermatitis
Vasculitis
Basal cell or squamous cell carcinoma
Lipodermatosclerosis
Lymphedema
Eosinophilic cellulitis
Other eczematous diseases

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Blood tests usually not indicated unless cellulitis and/or sepsis are suspected. Leukocytosis is more likely with true cellulitis (3).
If stasis dermatitis is secondary to venous thrombosis, a thorough hematologic workup may be indicated to rule out hypercoagulability states.
Duplex ultrasound imaging may diagnose deep venous thrombosis or severe valve damage secondary to past thrombosis.
Potentially more accurate gold standards (e.g., skin biopsy) would introduce considerable risk to study patients and would not be acceptable from an ethical standpoint (3)

Diagnostic Procedures/Other

Rule out arterial insufficiency (check peripheral pulses); ankle brachial pressure index (ABPI or ABI).
Check for diabetes.

Test Interpretation

ABPI <0.8 is suggestive of arterial insufficiency.
ABPI can be falsely elevated in diabetic patients and others with distal small vessel calcifications.
Arterial duplex ultrasound and angiography are the gold standards.

TREATMENT

GENERAL MEASURES

Primary role of treatment is to reverse effects of venous HTN.
Typically outpatient:
- Reduce edema:
  - Leg elevation: heels higher than knees; knees higher than hips
  - Compression therapy: elastic bandage wraps: ace bandages or Unna paste boot (zinc gelatin) or compression stockings (Jobst or nonfitted type) (7)[A]
  - Graduated elastic compression of 30 to 40 mm Hg at the ankle improves ulcer healing rate and may prevent ulcer recurrence (7)[A].
  - No specific type of topical dressing (hydrocolloid versus simple nonadherent dressing) superior to another when used with compression therapy to maintain moist wound environment. Multilayer or bilayer compression bandages-more effective than nonelastic or short stretch bandages for severe cases (7)[A].
  - High compression is contraindicated in arterial insufficiency; pneumatic compression devices (7)[A].
- Treat infection: Debride the ulcer base of necrotic tissue.
Activity:
- Avoid standing still.
- Stay active and exercise regularly.
- Elevate foot of bed unless contraindicated.
Inpatient, for endovascular radiofrequency ablation, vein stripping, sclerotherapy, or skin grafts; treatment of advanced cellulitis or venous ulcers
- Venous ulcer treatment includes autolytic, biologic, chemical, mechanical, and surgical.

MEDICATION

First Line

Topical moisturizers, emollients, and barrier creams (e.g., white petroleum, lanolin, etc.) aid with antipruritic treatment via reducing transepidermal water loss (8)[B].
No evidence for routine use of systemic or topical antibiotics unless clear evidence of infection (9)[A]
Uncomplicated stasis dermatitis can be treated with short courses of topical steroids (8,10[B]. (Topical triamcinolone 0.1% cream/ointment TID or betamethasone valerate 0.1% cream/ointment/solution TID) (10)]B].
Topical antipruritic: pramoxine, camphor, menthol, and doxepin 5% cream (8)[B]
Antipruritic medications (e.g., diphenhydramine, cetirizine hydrochloride, desloratadine) (8)[B]
Pentoxifylline (400 mg TID) is effective in treating venous leg ulcer and may be effective in the absence of compression (11)[A].
Enteric-coated aspirin (at least 300 mg) daily improves venous ulcer healing. (12)[B].
In light of increasing bacterial resistance to antibiotics, current guidelines recommend the use of antibacterial preparations only for clinical infection (cellulitis, increased pain, warmth, malodorous exudate) not for bacterial colonization (9)[A].
Current evidence does not support the routine use of honey or silver-based products. (9)[A]
There is no reliable evidence in the effectiveness of topical preparations such as povidone-iodine, peroxide based preparations, mupirocin, chlorhexidine (9)[A].
Insufficient evidence exists to either support or refute the routine use of silver sulfadiazine (SSD) for ambulatory patients with either partial-thickness burns or stasis dermatitis ulcers to decrease mortality, prevent infection, or augment wound healing (9)[A].
If secondary infection, treat with PO antibiotics for Staphylococcus or Streptococcus organisms (e.g., dicloxacillin 250 mg QID, levofloxacin 500 mg QD, clindamycin 300 mg QID or trimethoprim-sulfamethoxazole DS BID (3)[B].

Second Line
Consider antibiotics on basis of culture results of exudate from infected ulcer craters.

ISSUES FOR REFERRAL

Consider referral for nonhealing ulcer.
Arterial insufficiency
Uncertain diagnosis
Rheumatoid arthritis
Patch testing to evaluate for contact dermatitis
Associated disease (e.g., symptomatic varicose veins)

ADDITIONAL THERAPIES

If the patient is on amlodipine therapy, consider discontinuing amlodipine (13)[B].

SURGERY/OTHER PROCEDURES

Sclerotherapy and surgery may be required for associated disease.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

If Unna boot compression is used: Cut off and reapply boot once a week. Unna boots reduce edema by compression and prevent scratching.
Regular use of high compression stockings reduces chance of recurrent venous ulcer (14)[A].

DIET

lose weight, if overweight.

PATIENT EDUCATION

Encourage staying active to keep circulation and leg muscles in good condition. Walking is ideal.
Keep legs elevated while sitting or lying.
Do not wear girdles, garters, or pantyhose with tight elastic tops.
Do not scratch.
Avoid leg injury.
Elevate foot of bed with 2- to 4-inch blocks.
Apply compression stockings prior to getting out of bed when less edema is present. Regular use of high compression stockings may prevent recurrence of venous ulcers.

PROGNOSIS

Chronic course with intermittent exacerbations and remissions
The healing process for ulceration is often prolonged and may take months.

COMPLICATIONS

Sensations of itching, pain, and burning have negative impact on the quality of life (2)[B].
Secondary bacterial infection
DVT
Bleeding at dermatitis sites
Squamous cell carcinoma in edges of long-standing stasis ulcers
Scarring, which in turn leads to further compromise to blood flow and increased likelihood of minor trauma

REFERENCES

11 Beauregard S, Gilchrest BA. A survey of skin problems and skin care regimens in the elderly. Arch Dermatol. 1987;123(12):1638-1643.22 Duque M, Yosipovitch G, Chan YH, et al. Itch, pain, and burning sensation are common symptoms in mild to moderate chronic venous insufficiency with an impact on quality of life. J Am Acad Dermatol. 2005;53(3):504-508.33 David CV, Chira S, Eells SJ, et al. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011;17(3):1.44 Bailey E, Kroshinsky D. Cellulitis: diagnosis and management. Dermatol Ther. 2011; 24(2):229-239.55 Farage MA, Miller KW, Berardesca E, et al. Clinical implications of aging skin: cutaneous disorders in the elderly. Am J Clin Dermatol. 2009;10(2):73-86.66 Weaver J, Billings SD. Initial presentation of stasis dermatitis mimicking solitary lesions: a previously unrecognized clinical scenario. J Am Acad Dermatol. 2009;61(6):1028-1032.77 O'Meara S, Cullum N, Nelson EA, et al. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2012;(11):CD000265.88 Patel T, Yosipovitch G. Therapy of pruritus. Expert Opin Pharmacother. 2010;11(10):1673-1682.99 O'Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database Syst Rev. 2014;(1):CD003557.1010 Weiss SC, Nguyen J, Chon S, et al. A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis. J Drugs Dermatol. 2005;4(3):339-345.1111 Jull A, Arroll B, Paraq V, et al. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst Rev. 2007;(3):CD001733.1212 Layton AM, Ibbotson SH, Davies JA, et al. Randomised trial of oral aspirin for chronic venous leg ulcers. Lancet. 1994;344(8916):164-165.1313 Gosnell AL, Nedorost ST. Stasis dermatitis as a complication of amlodipine therapy. J Drugs Dermatol. 2009;8(2):135-137.1414 Nelson EA, Bell-Syer SE, Cullum NA. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2000;(4):CD002303.

ADDITIONAL READING

Collins L, Seraj S. Diagnosis and treatment of venous ulcers. Am Fam Physician. 2010;81(8):989-996.
Partsch H, Flour M, Smith PC; International Compression Club. Indications for compression therapy in venous and lymphatic disease consensus based on experimental data and scientific evidence. Under the auspices of the IUP. Int Angiol. 2008;27(3):193-219.
Sippel K, Mayer D, Ballmer B, et al. Evidence that venous hypertension causes stasis dermatitis. Phlebology. 2011;26(8):361-365.

CODES

ICD10

I83.10 Varicose veins of unsp lower extremity with inflammation
I83.11 Varicose veins of right lower extremity with inflammation
I83.12 Varicose veins of left lower extremity with inflammation
I87.2 Venous insufficiency (chronic) (peripheral)
I83.209 Varicos vn unsp low extrm w ulc of unsp site and inflam

ICD9

454.1 Varicose veins of lower extremities with inflammation
459.81 Venous (peripheral) insufficiency, unspecified
454.8 Varicose veins of lower extremities with other complications
454.2 Varicose veins of lower extremities with ulcer and inflammation

SNOMED

35498005 Stasis dermatitis (disorder)
275700003 Varicose veins of the leg with eczema
234050002 Venous insufficiency of leg
304026004 varicose ulcer of lower extremity (disorder)

CLINICAL PEARLS

Treatment of edema associated with stasis dermatitis via elevation and/or compression stockings is essential for optimal results.
Pentoxifylline 1,200 mg daily and aspirin 300 mg daily improve venous ulcer healing.
No difference in healing rate of venous stasis ulcers by use of hydrocolloid dressing versus simple nonadherent dressing when used beneath compression. Decision about the dressing should be based on local cost and patient or physician's preferences (7)[A].
Mild topical corticosteroids reduce inflammation and itching; however, these may potentiate infection; high-potency topical corticosteroids should be avoided due to increased risk of atrophy and ulceration.

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