DESCRIPTION

• Chronic, eczematous, scaling, erythematous plaques, and patches to the lower extremities accompanied by cycle of scratching, excoriations, weeping, crusting, and inflammation in patients with chronic venous insufficiency (CVI) and edema; clinical skin manifestation of CVI usually appears late in the disease; may present as a solitary lesion most often starting on medial ankle; can be associated with venous leg ulcers on bony prominences.
• System(s) affected: skin/exocrine
• Synonym(s): gravitational eczema; varicose eczema; venous dermatitis; stasis eczema

EPIDEMIOLOGY

ETIOLOGY AND PATHOPHYSIOLOGY

• Due to venous hypertension from venous incompetence (valve dysfunction and reflux) or obstruction (thrombosis or stenosis) of superficial, perforating, or deep veins
• Inflammatory changes include microvascular abnormalities (leaking capillaries with fibrin cuffs, thickened venules, microthrombosis) and increased leukocytes (macrophages, T lymphocytes, mast cells).
• Usually with chronic dependent edema; inflamed, edematous skin may be more susceptible to trauma.
• 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.

RISK FACTORS

• Atopy, chronic edema, superimposition of itch–scratch cycle
• Old age, obesity
• Cigarette use
• Previous DVT, previous pregnancy, hx vein stripping, vein harvesting for coronary artery bypass graft surgery
• Prolonged standing or sitting
• Hypertension, congestive heart failure
• Trauma
• Low-protein diet
• High-estrogen states
• Genetic propensity (familial history of congenital disease)

GENERAL PREVENTION

• Treat lower extremity edema with compression stockings, exercise, and leg elevation. This will mobilize the interstitial lymphatic fluid from the region of stasis dermatitis; also following DVT.
• Consider early treatment of venous insufficiency with specialist care and interventional procedures as indicated.
• Use topical emollients twice a day to prevent fissuring and itching.

COMMONLY ASSOCIATED CONDITIONS

Varicose veins, venous insufficiency, other eczematous disease, hyperhomocysteinemia, venous HTN