Description

• Chronic, eczematous, erythema, scaling, and noninflammatory edema of the lower extremities accompanied by cycle of scratching, excoriations, weeping, crusting, and inflammation in patients with chronic venous insufficiency (CVI), due to impaired circulation and other factors (nutritional edema)
• Clinical skin manifestation of CVI usually appears late in the disease.
• May present as a solitary lesion; can be associated with venous leg ulcer, which is located on the medial or lateral side of the ankle
• System(s) affected: skin/exocrine
• Synonym(s): gravitational eczema; varicose eczema; venous dermatitis

Epidemiology

Incidence

• In the United States: common in patients age >50 years (6–7%)
• Predominant age: adult, geriatric
• Predominant sex: female > male

Geriatric Considerations
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, superficial venous thrombosis from varicose veins, and deep vein thrombosis (DVT) can each contribute to CVI leading to venous hypertension (HTN) and cutaneous inflammation. This can be a pathway to venous leg ulcer.
• 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, eczematized 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

• Atopy
• Chronic edema
• Old age
• Obesity
• Previous DVT
• Previous pregnancy
• Prolonged standing
• Secondary infection
• Superimposition of itch–scratch cycle
• Trauma
• Low-protein diet
• Genetic propensity
• 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