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

Epidemiology

Incidence
In the United States: common in patients aged >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 aged >50 years in the United States

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.

Genetics
Familial link probable

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
• 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 and 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