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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, pruritus, pain, tenderness [3] 4) petechiae 5) hyperpigmentation (reddish-brown discoloration from hemosiderin) 6) pruritus, weeping, scaling, erosions, excoriations from scratching - may weep serous fluid or blister 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) 12) most cases bilateral [3] 13) diminished pulses may be related to edema * images [5,6,7] Laboratory: - complete blood count (CBC) - rule out cellulitis - WBC is normal with statis dermatitis, but may be elevated with cellulitis Special laboratory: - OpenEvidence suggests duplex ultrasonography is recommended to assess for venous reflux, obstruction, & to clarify extent of chronic venous disease, especially in the presence of advanced skin changes & diminished pedal pulses - MKSAP20 says bilateral lower extremity ultrasonography is used when deep venous thrombosis is suspected [3] Differential diagnosis: - cellulitis - factors favoring cellulitis vs stasis dermatitis - acute vs chronic* - unilateral vs bilateral* - pain vs pruritus - smooth skin vs scaling, fibrotic plaques - sharp demarcation - stasis dermatitis may have well-demarcated patches - fever/chills, myalgia variable with cellulitis - absent with stasis dermatitis - brown discoloration may occur with stasis dermatitis - WBC count is normal with stasis dermatitis - lipodermatosclerosis - pitting edema favors stasis dermatitis over lipodermatosclerosis, especially in the absence of significant induration or fibrosis * stasis dermatitis more likely than cellulitis in patients presenting with bilateral erythema & swelling of the legs even when presentation is acute (MKSAP12) [3] Complications: - chronic venous ulcers - lipodermatosclerosis 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; chronic venous insufficiency

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, 20. American College of Physicians, Philadelphia 2009, 2012, 2015, 2025 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  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. Geriatric Review Syllabus, 11th edition (GRS11) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2022
  9. Stasis dermatitis (image) American Academy of Dermatology https://www.aad.org/public/diseases/eczema/stasis-dermatitis
  10. Yosipovitch G, Nedorost ST, Silverberg JI et al Stasis Dermatitis: An Overview of Its Clinical Presentation, Pathogenesis, and Management. Am J Clin Dermatol. 2023 Mar;24(2):275-286. PMID: 36800152 PMCID: PMC9968263 Free PMC article. Review. - Yosipovitch G, Jackson JM, Nedorost ST, et al. Stasis dermatitis: the burden of disease, diagnosis, and treatment. Dermatitis. 2024;35:337-344. PMID: 37782143