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stasis dermatitis; venous eczema; gravitational dermatitis

Etiology: - chronic venous stasis - possible contributing factors a) venous hypertension - congestive heart failure b) chronic inflammation c) microangiopathy Pathology: 1) inflammation of the skin (dermatitis) from venous stasis 2) scarring, atrophy & hyperpigmentation of the skin 3) fibrosis, lipodermatosclerosis 4) associated with leg trauma & varicose veins Clinical manifestations: 1) gradual manifestations can persist for months to years [3] 2) most commonly on the legs below the knee, dorsal surface of the feet & around the medial malleolus 3) edema, erythema, warmth 4) petechiae 5) hyperpigmentation (reddish-brown discoloration from hemosiderin) 6) pruritus, weeping, scaling, erosions, excoriations from scratching 7) ulcerations common around the medial malleolus 8) sharp demarcation uncommon 9) varicose veins generally visible 10) pruritus may generalize over entire body (id reaction) 11) crusting (dermatitis medicamentosa) * images [5,6,7] Laboratory: - complete blood count (CBC) - rule out cellulitis - WBC is normal with statis dermatitis, but may be elevated with cellulitis Differential diagnosis: - cellulitis - factors favoring cellulitis vs stasis dermatitis - acute vs chronic - pain vs pruritus - unilateral vs bilateral - smooth skin vs scaling, fibrotic plaques - sharp demarcation - fever/chills, myalgia variable with cellulitis - absent with stasis dermatitis - brown discoloration may occur with stasis dermatitis - WBC count is normal with stasis dermatitis Management: 1) topical agents a) glucocorticoids [7] b) becaplermin (Regranex) 0.1% c) Dovonex 0.005%, apply BID 2) long-term non-pharmaceutical meaasures a) compression b) leg elevation c) emollients 3) avoid topical antibiotics due to risk of allergic sensitization [4]

Related

venous stasis; venous hypertension

Specific

dermatitis medicamentosa

General

eczematous dermatitis (eczema)

References

  1. DeGowin & DeGowin's Diagnostic Examination, 6th edition, RL DeGowin (ed), McGraw Hill, NY 1994, pg 878
  2. Ferri's Clinical Advisor, Instant Diagnosis and Treatment, Ferri FF (ed), Mosby, Philadelphia, 2003
  3. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17. American College of Physicians, Philadelphia 2009, 2012, 2015
  4. Choosing Wisely. Feb 23, 2015 Infectious Diseases Society of America Five Things Physicians and Patients Should Question http://www.choosingwisely.org/doctor-patient-lists/infectious-diseases-society-of-america/
  5. DermNet NZ. Venous eczema (images) http://www.dermnetnz.org/dermatitis/venous-eczema.html
  6. Flugman SL, Elsto DM (images) Medscape: Stasis Dermatitis http://emedicine.medscape.com/article/1084813-overview
  7. Weiss SC, Nguyen J, Chon S, Kimball AB. 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 May-Jun;4(3):339-45. PMID: 15898290
  8. Stasis dermatitis (image) American Academy of Dermatology https://www.aad.org/public/diseases/eczema/stasis-dermatitis