Stasis Dermatitis

Stasis dermatitis is a common reactive inflammatory condition that affects the lower extremities. In the Framingham Heart Study, 1 in 20 patients older than 65 had stasis dermatitis. Stasis dermatitis defines a spectrum of cutaneous findings that represent acute and/or chronic effects of venous hypertension. The most common pathologic cause is dysfunctional or incompetent venous valves that lead to decreased venous outflow and pooling of blood in the veins of the lower extremities. As a result, microvascular leakage of blood results in edema, inflammation, and skin changes. Other common pathologic states leading to venous hypertension include outflow obstruction (e.g., thrombosis, stenosis); chronic lower-extremity edema from heart, kidney, or liver failure; or failure of the calf-muscle pump due to obesity or immobility.

The following table describes pathologic paths leading to stasis dermatitis (referred to as inflammation).

(Source: Chronic Venous Disease. N Engl J Med 2006).

Clinical Manifestations

Stasis dermatitis findings depend on chronicity. In the acute phase (hours to days), skin is commonly bright red with weeping, vesicles, or both; tenderness is common in this phase. Chronic stasis dermatitis (weeks to years) is characterized by hyperpigmentation with induration and medial malleolus ulceration. Consistent findings among all time frames include symmetry and a history of edema. Cutaneous findings of lymphatic dysfunction can be seen in areas of chronic venous stasis after many years.

(Source: Chronic Venous Disease. N Engl J Med 2006.)

(Source: Chronic Venous Insufficiency and Varicose Veins. N Engl J Med 2009.)

(Source: Chronic Venous Disease. N Engl J Med 2006.)

(Source: Chronic Venous Disease. N Engl J Med 2006.)

(Source: Chronic Venous Disease. N Engl J Med 2006.)

(Source: Elephantiasis Nostras Verrucosa. N Engl J Med 2014.)

(Source: Papillomatosis Cutis Lymphostatica. N Engl J Med 2014.)

(Source: Cellulitis. N Engl J Med 2004.)

Diagnosis

Diagnosis of stasis dermatitis is primarily clinical, based on characteristic skin changes (erythema, scaling, hyperpigmentation, edema, crusting, papillomatosis, and/or ulceration), as well as signs of chronic venous insufficiency (varicose veins, edema, hyperpigmentation). Doppler studies of the lower extremities can help to confirm the presence of venous insufficiency.

In acute or subacute presentations, consider the following alternative diagnoses:

• systemic volume overload (e.g., hepatic failure, renal failure, congestive heart failure)

• drug-induced edema (e.g., amlodipine)

• venous thrombosis

• arterial insufficiency

Note: Bacterial cellulitis is rarely the diagnosis in the setting of bilateral lower-extremity redness.

Treatment

Stasis dermatitis treatment is directed at both the underlying cause (chronic venous insufficiency) and the inflammatory condition itself.

Approach to chronic insufficiency:

• treatment of systemic disease (e.g., diuresis for congestive heart failure)

• consideration of stopping medications known to cause edema (e.g., amlodipine, prednisone, nonsteroidal anti-inflammatories; full list of potential medications found here)

• lifestyle modification (weight loss, walking, leg elevation at night)

• lifelong compression stockings (>30 mm Hg)

• drug therapy (pentoxifylline)

• surgical corrective procedures (e.g., vein ablation, deep venous valve reconstruction, interruption of the perforator veins)

Acute stasis dermatitis management:

• ultra-potent topical glucocorticoid ointment (e.g., clobetasol)

  • fast onset of action

  • apply twice daily for no more than 2 weeks

• compression and elevation of the lower extremities as much as possible (compression stockings can be removed during sleep, but legs should remain elevated above the level of the heart)

• maintenance therapy with daily emollient to prevent xerosis (dry skin)