Venous Stasis Dermatitis and Venous Ulcers

Stasis dermatitis (also called venous stasis dermatitis) is an inflammatory reaction seen in the skin of the lower leg caused by static (slow or delayed) venous flow of the leg. Stasis dermatitis is common in patients 50 years and older. Factors that can contribute to the early onset of stasis dermatitis include obesity, inactivity, venous injury, dependency (lower than the heart) of the leg and infection of the leg. The primary contributing cause of stasis dermatitis is valvular incompentency of the veins of the leg resulting in chronic edema (swelling). The appearance of venous stasis can range from simple swelling to severe ulcerations (see symptoms, below).

Left untreated, venous stasis can progress to a venous ulceration.  The most common location for a venous ulceration of the lower extremity is over the medial aspect of the ankle.  Venous ulcerations vary in size and depth.

Treatment of stasis dermatitis and venous stasis ulcers.

Central to the treatment of venous stasis dermatitis and venous stasis ulcers is control of lower extremity edema. Edema can be controlled by elevating the legs above the level of the heart, use of diuretics and the use of compression hose. It's important to realize that when using compression hose, the hose need to be put on first thing in the morning in advance of any swelling. If swelling is allowed to occur before applying the support hose, that swelling will likely be there the rest of the day.

Eczematous changes (peeling and flaking) and lichenification (hardening of the epidermis) can be treated with skin softening agents. Inflammatory changes of the skin are common and can be treated with topical or oral steroids. Discoloration of the skin is difficult to treat. Discoloration or darkening of the skin is often due to the deposition of hemosiderin (the iron component of red blood cells). Once hemosiderin is deposited in the skin, is is much like a tattoo that stains the skin from within.

Ulceration of the skin is common, particularly at the medial (inside) ankle. The area superficial to the origin of the great saphenous vein is the most common site of ulceration. Ulcerations should be cultured and treated for infection if necessary. Dome paste boots, also called an Unna boots are the gold standard for treating venous stasis ulcerations. Dome paste boot are saturated with zinc oxide that will moisturize the skin. Dome past boots are applied on a one weekly basis to control lower extremity edema. Treatment can take from one to many weeks to see complete closure of the venous ulcer.  Negative pressure treatment of the wound along with skin grafting may be necessary in severe, non-healing ulcers.

It is essential to realize that control of edema is necessary following successful treatment of a venous stasis ulcer. Compression hose should be worn daily to prevent reoccurrence of ulcerations.

Dependency - this is the term used to describe the position the leg is in while sitting.  When positioned lower than the heart, the leg will swell.  Dependency is the position of the leg that would be considered the opposite of elevating the leg.
Dermatitis - an inflammatory reaction of the skin.  Dermatitis varies in its' severity and cause. 
Eczemification - early changes of the skin that include erythema (redness) and peeling of the skin.
Indurated - firm thickening of the skin and subcutaneous tissues.
Lichenification - late changes that include thickening and scaling of the skin.
Stasis - static or non-flowing.
Venous - relating the the veins.  Veins are the return loop of circulation carrying blood towards the heart.

The function of the venous system of the leg is to return blood from the foot back to the heart.  The lower extremity venous system consists of three types of veins; superficial, perforator and deep veins.  Veins are very similar to arteries with the exception that veins have less muscle and must subsequently carry a lower intra-luminal pressure.  Most veins contain valves that open with blood flow to the heart and close with a reversal of flow.  The purpose of the valves is to insure unidirectional flow of blood to the heart.  The veins of the leg are unique in that they also use muscular contraction to drive blood to the heart.  This pump is called the calf pump.  While walking, compression of the vein by the muscle helps to facilitate blood flow to the heart.

The two primary superficial veins of the leg are the great saphenous and the small saphenous veins.  While standing, the pressure in each of these veins is equal to the pressure that would be found in a column of blood extending from the foot to the heart.  When the calf pump is activated, blood is pumped proximally through the perforator veins into the deep veins.  The deep veins of the leg include the posterior tibial vein, anterior tibial vein, popliteal vein and femoral vein.

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The symptoms of stasis dermatitis vary with the general health of the patient, duration of the condition and status of treatment. Early stasis dermatitis shows a red blush surrounding the lower 1/3 of the leg. Stasis dermatitis is usually found in both legs with a symmetrical presentation. Pigmentation changes (darkening) of the leg usually follows a prolonged period of swelling (edema) of the lower leg.

As the duration of edema continues, stasis dermatitis will worsen with eczematization of the leg. Eczematization is the thickening of the skin with lichenification. Lichenification describes crusting and layering of the skin that occurs when the normal exfoliative properties of the skin are disrupted by chronic swelling. In this stage of stasis dermatitis, oozing, scaling and deep pigmentation changes in the skin may become apparent. The skin and deeper tissues of the lower leg will also become indurated (firm).

If left untreated, stasis dermatitis will continue to the final stage where the skin ulcerates due to the back pressure caused by venous incompentency. In this stage, the leg will open and weep fluid. Infection may also become a secondary issue due to a breach in the skin.

The differential diagnosis for this condition should include;

Pretibial myxedema

Cellulitis

• Skin

• Varicose Vein

• Peripheral Arterial Disease

• Cracked Heel

• Dermatitis

Cutaneous Disorders of the Lower Extremities 2nd Edition., M H Samitz, MD.  J.P Lippincott Company, Philadelphia, 1981.