Venous eczema

What is venous eczema?

Venous eczema is a common form of eczema/dermatitis that affects one or both lower legs in association with venous insufficiency. It is also called gravitational dermatitis.

Who gets venous eczema?

Venous eczema is most often seen in middle-aged and older patients — it is reported to affect 20% of those over 70 years. It is associated with:

• History of deep venous thrombosis in an affected limb
• History of cellulitis in an affected limb
• Chronic swelling of the lower leg, aggravated by hot weather and prolonged standing
• Varicose veins
• Stasis ulcers.

What causes venous eczema?

Venous eczema appears to be due to fluid collecting in the tissues and activation of the innate immune response.

Normally during walking the leg muscles pump blood upwards and valves in the veins prevent pooling. A clot in the deep leg veins (deep venous thrombosis or DVT) or varicose veins may damage the valves. As a result back pressure develops and fluid collects in the tissues. An inflammatory reaction occurs.

What are the clinical features of venous eczema?

Venous eczema can form discrete patches or become confluent and circumferential. Features include:

• Itchy red, blistered and crusted plaques; or dry fissured and scaly plaques on one or both lower legs
• Orange-brown macular pigmentation due to haemosiderin deposition
• Atrophie blanche (white irregular scars surrounded by red spots)
• 'Champagne bottle' shape of the lower leg — narrowing at the ankles and induration (lipodermatosclerosis)

Venous eczema 

Lipodermatosclerosis 

Venous ulcer 

What are the complications of venous eczema?

• Impetiginisation — secondary infection with Staphylococcus aureus resulting in yellowish crusts
• Cellulitis — infection with Streptococcus pyogenes: there may be redness, swelling, pain, fever, a red streak up the leg, and swollen nodes in the groin
• Secondary eczema — eczema spreads to other areas on the body
• Contact allergy to one or more components of the ointments or creams used

How is venous eczema diagnosed?

The diagnosis of venous eczema is clinical.

Patch tests may be undertaken if there is suspicion of contact allergy.

What is the treatment for venous eczema?

Reduce swelling in the leg

• Don't stand for long periods.
• Take regular walks.
• Elevate your feet when sitting: if your legs are swollen they need to be above your hips to drain effectively.
• Elevate the foot of your bed overnight.
• During the acute phase of eczema, bandaging is important to reduce swelling.
• When eczema has settled, wear graduated compression socks or stockings long term. Fitted moderate to high compression socks can be obtained from a surgical supplies company. Light compression using travel socks may be adequate, and these are easy to put on. They can be bought at pharmacies, travel and sports stores. More compression is obtained by wearing two pairs.
• Horse chestnut extract appears to be of benefit for at least some patients with venous disease.

Treat the eczema

• Dry up oozing patches with Condy's solution (potassium permanganate) or dilute vinegar on gauze as compresses.
• Oral antibiotics such as flucloxacillin may be prescribed for a secondary infection.
• Apply a prescribed topical steroid: start with a potent steroid cream applied accurately daily to the patches until they have flattened out. After a few days, change to a milder steroid cream (eg. hydrocortisone) until the itchy patches have resolved (maintenance treatment). Check with your doctor if you are using steroid creams for more than a few weeks. Overuse can thin the skin, but short courses of stronger preparations can be used from time to time if necessary to control dermatitis. Coal tar ointment may also help.
• Use a moisturising cream frequently to keep the skin on the legs smooth and soft. If the skin is very scaly, urea cream may be especially effective.
• Protect your skin from injury: this can result in infection or ulceration that may be difficult to heal.

Treatment for varicose veins

• Seek the opinion of a vascular surgeon regarding varicose veins.
• These can be treated surgically, by endovenous laser, or sclerotherapy.
• Varicose veins may develop again after an apparently successful operation because venous disease is progressive.

How can venous eczema be prevented?

Venous eczema cannot be completely prevented but the number and severity of flare-ups can be reduced by the following measures.

• Avoid prolonged standing or sitting with legs down.
• Wear compression socks or stockings.
• Avoid and treat leg swelling.
• Apply emollients frequently and regularly to dry skin.
• Avoid soap; use water alone or non-soap cleansers when bathing.

What is the outlook for venous eczema?

Venous eczema tends to be a recurring or chronic disorder lifelong. Treat recurrence promptly with topical steroids.