AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Stasis dermatitis is a common inflammatory skin disease that occurs on the lower extremities in patients with chronic venous insufficiency with venous hypertension. The condition typically affects middle-aged and elderly patients. It rarely occurs before the fifth decade of life, except in patients with acquired venous insufficiency due to surgery, trauma, or thrombosis. Stasis dermatitis is usually the earliest cutaneous sequela of venous insufficiency, and it may be a precursor to more problematic conditions, such as venous leg ulceration and lipodermatosclerosis.

Pathophysiology

Stasis dermatitis occurs as a direct consequence of venous insufficiency. Disturbed function of the 1-way valvular system in the deep venous plexus of the legs results in backflow of blood from the deep venous system to the superficial venous system, with accompanying venous hypertension. This loss of valvular function can result from an age-related decrease in valve competency. Alternatively, specific events, such as deep venous thrombosis, surgery (eg, vein stripping, harvesting of saphenous veins for coronary bypass), or traumatic injury, can severely damage the function of the lower-extremity venous system (see Image 2). The mechanism by which venous hypertension causes the cutaneous inflammation of stasis dermatitis has been extensively studied for decades. Several theories have been proposed.

The earliest theories regarding the cause of cutaneous inflammation in venous insufficiency centered on oxygen perfusion of lower-extremity tissues. Originally, an incompetent venous system was thought to lead to pooling of blood in the superficial veins, with reduced flow and therefore reduced oxygen tension in the dermal capillaries. This pooling hypothesis led to the term stasis dermatitis. It was believed that the decreased oxygen content of pooled blood led to hypoxic damage to the overlying skin.

The hypoxia/stasis theory was refuted by evidence that instead of pooled, stagnant blood with low oxygen tension, leg veins in patients with venous insufficiency have increased flow rates and high oxygen tension. Arteriovenous shunting could have accounted for these findings, but no evidence of shunting in patients with venous insufficiency was found. The complete lack of evidence to support a hypoxia/stasis theory has led many investigators to advocate the abandonment of the term stasis dermatitis.

Subsequent research focused on the role of lower-extremity microcirculation in the pathogenesis of skin damage due to venous insufficiency. In the 1970s and 1980s, increased venous hydrostatic pressure was found to be transmitted to the dermal microcirculation; this leads to increased permeability of dermal capillaries.

This increased permeability enables macromolecules, such as fibrinogen, to leak out into the pericapillary tissue; then, polymerization of fibrinogen to fibrin results in the formation of a fibrin cuff around dermal capillaries. It has been hypothesized that this fibrin cuff serves as a barrier to oxygen diffusion, with resulting tissue hypoxia and cell damage. Subsequently, the phenomenon of fibrin cuff formation was found in more severe disease, such as venous ulceration. Fibrin cuffs are not found in ulcers due to causes other than venous hypertension. Decreased cutaneous fibrinolytic activity has been proposed to contribute to the formation of fibrin cuffs.

Formation of fibrin cuffs, coupled with decreased fibrinolysis, results in the dermal fibrosis that is the hallmark of advanced stasis dermatitis. Activated leukocytes become trapped in fibrin cuffs and the surrounding perivascular space, releasing inflammatory mediators that contribute to inflammation and fibrosis. These leukocytes release the growth factor transforming growth factor-beta1, an important mediator of dermal fibrosis. Furthermore, upregulation of vascular intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1), which are potent chemoattractants to keep leukocytes active in the perivascular environment, occurs. The finding of leukocyte-mediated cytokine production, aided by fibrin cuff formation, provides a direct link between dysfunctional venous circulation and cutaneous inflammation with fibrosis.

Frequency

United States

Although not nearly as prevalent as skin cancer, dermatophytosis, or xerosis, stasis dermatitis affects a significant proportion of the elderly population. Studies have estimated the prevalence of stasis dermatitis to be approximately 6-7% in patients older than 50 years. This finding makes stasis dermatitis twice as prevalent as psoriasis and only slightly less prevalent than seborrheic dermatitis.

Mortality/Morbidity

No conclusive studies on morbidity and mortality in stasis dermatitis have been undertaken. However, a prevalence of 6-7% would translate into approximately 15-20 million patients older than 50 years with stasis dermatitis in the United States. Much of the morbidity stems from the complications of chronic stasis dermatitis, including cellulitis and nonhealing venous ulcers.

Sex

A slight female preponderance has been reported in stasis dermatitis. This is most likely due to the fact that pregnancy results in significant stress on the lower-extremity venous system, with many women experiencing earlier and more severe derangement of lower-extremity valvular function.

Age

The risk of developing stasis dermatitis steadily increases with each passing decade; when considering only adults older than 70 years, the prevalence of stasis dermatitis may be greater than 20%. The well-publicized aging of the population will undoubtedly result in a significant increase in cases of stasis dermatitis over the next few decades.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

• Patients with stasis dermatitis typically present with an insidious onset of pruritus affecting one or both lower extremities.
• Reddish-brown skin discoloration is an early sign of stasis dermatitis and may precede the onset of symptoms.
• The medial ankle is most frequently involved, with symptoms progressing to involve the foot and/or the calf.
• The patient may offer a prior history of dependent leg edema.
• Factors that worsen peripheral edema (eg, congestive heart failure, long-standing hypertension with diastolic dysfunction) are often found in patients with stasis dermatitis.

Physical

Physical examination reveals erythematous, scaling, eczematous patches affecting the lower extremity (see Image 1).

• The medial ankle is most frequently and severely involved because of the fact that the medial ankle represents a watershed area with relatively poor blood flow compared with the rest of the leg. In advanced cases of stasis dermatitis, the inflammation may encircle the ankle and extend to just below the knee; this is sometimes referred to as stocking erythroderma. The dorsal part of the foot may be involved in severe cases.
• Involved skin in stasis dermatitis may exhibit the same changes as seen in other eczematous conditions.
• • Severe, acute inflammation may result in exudative, weeping patches and plaques.
  • Secondary infection can cause typical honey-colored crusting due to bacteria or monomorphous pustules due to cutaneous candidiasis.
  • In long-standing lesions, lichenification and hyperpigmentation may occur as a consequence of chronic scratching and rubbing. In addition to lichenification and hyperpigmentation, chronic stasis dermatitis can show changes, such as skin induration, which may progress to lipodermatosclerosis with the classic inverted champagne bottle appearance.
  • Another unique feature sometimes seen in chronic stasis dermatitis is the development of violaceous plaques and nodules on the legs and dorsal part of the feet. These lesions frequently undergo painful ulceration and can be clinically indistinguishable from classic Kaposi sarcoma. This clinical appearance has led this entity to be called pseudo–Kaposi sarcoma or acroangiodermatitis.
• Stasis dermatitis frequently occurs along with a background of skin changes that are typical for patients with venous insufficiency.
• • These skin changes include edema, varicosities, hyperpigmentation, atrophic patches (atrophie blanche), and diffuse red-brown discoloration representing deep dermal deposits of hemosiderin (from degraded, extravasated erythrocytes).
  • These chronic changes persist regardless of the activity of stasis dermatitis.

Causes

See Pathophysiology.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Lab Studies

• Blood tests are generally not helpful in the management of stasis dermatitis, except in a patient where cellulitis and/or sepsis are suspected. An exception is the patient with stasis dermatitis due to venous thrombosis; patients with venous thrombosis need a thorough hematologic workup to rule out underlying hypercoagulability states.

Imaging Studies

• Radiologic/Doppler studies
• • In patients with acute new-onset stasis dermatitis or in a young patient, investigating the dynamics of the deep venous circulation is prudent.
  • Venous Doppler studies may reveal deep venous thrombosis or severe valve damage due to past thrombosis. Of course, the consequences of an unrecognized acute or subacute deep venous thrombosis may be catastrophic.

Histologic Findings

Skin biopsy of stasis dermatitis, although rarely indicated, shows an acute or subacute dermatitis. Acute lesions may exhibit a superficial perivascular lymphocytic infiltrate, epidermal spongiosis, serous exudate, scale, and crust. Chronic lesions may show epidermal acanthosis with hyperkeratosis. The dermis is characterized by deep dermal aggregates of siderophages due to uptake of hemosiderin from degraded erythrocytes. Dermal capillaries are frequently dilated; long-standing lesions show intimal thickening of small arterioles and venules along with dermal fibrosis.

A special consideration in chronic stasis dermatitis where biopsy may be necessary is the development of acroangiodermatitis (pseudo–Kaposi sarcoma). The violaceous plaques and nodules of acroangiodermatitis may be clinically indistinguishable from classic Kaposi sarcoma, especially when occurring in an elderly man. Biopsy samples show changes typical of stasis dermatitis, along with a proliferation of capillaries and fibroblasts. However, the vascular slits and the atypical endothelial cells that are seen in classic Kaposi sarcoma are absent.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Medical Care

• Compression therapy
• • Although extensive work has been completed in the study of treatment of venous ulcers, no large, well-controlled trials examine the treatment of stasis dermatitis. The overall mainstay of treatment has always been aimed at lessening the clinical impact of the underlying venous insufficiency, which is typically accomplished with compression therapy. Assessing the patient's peripheral arterial circulation (clinically or with a Doppler study) before recommending compression therapy is important; adding compression to a leg with compromised arterial circulation could increase claudication and put the patient at risk for ischemic damage.
  • Compression is generally accomplished by means of specialized stockings that deliver a controlled gradient of pressure (measured in mm Hg) to the affected leg. More aggressive compression can be performed by using elastic wraps; compression (Unna) boots; and more sophisticated devices, such as end-diastolic compression boots. Most of these modalities require administration in a physician's office or wound care center. Frequent leg elevation is a necessary adjunct to leg compression.
  • Counseling patients regarding the use of compression therapy is vital to successful management of stasis dermatitis. Patients frequently resist the idea of compression dressings and/or stockings because these modalities may cause considerable discomfort when first applied to edematous, inflamed lower extremities. However, it is important to reassure patients that this discomfort will lessen considerably as leg edema is reduced, and this therapy must be maintained permanently in order to prevent a recurrence of dermatitis and leg ulcers. Compression stockings should be applied early in the morning, before the patient rises from bed, in order to facilitate application when leg edema is at its lowest point.
• Topical therapy
• • Topical treatment of stasis dermatitis has much in common with the treatment of other forms of acute eczematous dermatitis. Weeping lesions can be treated with wet-to-damp gauze dressings soaked with water or with a drying agent, such as aluminum acetate. Topical corticosteroids are frequently used for reducing inflammation and itching in acute flares; mid-potency corticosteroids, such as triamcinolone 0.1% ointment, are generally effective.
  • Be wary of the use of high-potency topical corticosteroids in stasis dermatitis because the chronically inflamed skin can increase the risk of systemic absorption and because steroid-induced cutaneous atrophy can predispose the patient to ulceration. Furthermore, prolonged use of topical steroids can lead to decreased efficacy of the steroid, a phenomenon known as tachyphylaxis. Systemic corticosteroids are not part of stasis dermatitis treatment, although they may be required in very severe cases of widespread autoeczematization.
  • The recently approved nonsteroidal calcineurin inhibitors tacrolimus and pimecrolimus may prove to be useful tools in the management of stasis dermatitis. Although these topical medications are approved only for atopic dermatitis, they have been shown to be effective in many steroid-responsive dermatoses. Because the calcineurin inhibitors do not carry the risks of skin atrophy or tachyphylaxis, they have the potential to become valuable agents in the treatment of chronic dermatoses such as stasis dermatitis.
• Prevention/management of infection
• • Be wary of infection in stasis dermatitis; this becomes more problematic when using topical corticosteroids, which make the patient more susceptible to infection.
  • Open excoriations and erosions should be treated with a topical antibiotic, such as bacitracin or Polysporin. Obvious superficial impetiginization should be treated with topical mupirocin or a systemic antibiotic with activity against Staphylococcus and Streptococcus species (eg, dicloxacillin, cephalexin, cefadroxil, levofloxacin).
  • Culture with sensitivity testing is important when managing suspected superinfection because community-acquired methicillin resistance is becoming increasingly prevalent.
  • Expanded coverage may be necessary in patients who are immunocompromised.
  • Suspected deep cellulitis should always be treated with oral or intravenous antibiotics. Necrotizing fasciitis would be a rare complication but is a surgical emergency.
• Complications of treatment - Allergic contact dermatitis
  • The development of contact dermatitis is especially problematic in the treatment of patients with stasis dermatitis. Chronic inflammation of the skin, coupled with the use of multiple topical medications (both prescription and over-the-counter) frequently result in contact sensitization as a complication of stasis dermatitis. Patients should be instructed to not apply over-the-counter antibiotics or other topical agents without the direction of a physician.
  • Some of the most frequent contact allergens complicating stasis dermatitis include the topical antibiotics neomycin and bacitracin. In addition, affected patients may become sensitized to rubber products that are found in some wraps and stockings. Topical corticosteroid allergy, while uncommon, is a condition that can worsen stasis dermatitis despite seemingly appropriate prescription therapy.
  • Consider contact dermatitis in any patient with stasis dermatitis who becomes clinically worse despite appropriate topical treatment.
• Long-term management
  • Patients with chronic, quiescent stasis dermatitis can be treated with bland topical emollients to maximize epidermal moisture.
  • Plain white petrolatum is an inexpensive occlusive moisturizer that is very effective and, importantly, does not contain any contact sensitizers.

Consultations

Uncomplicated stasis dermatitis is usually managed in the dermatologist's office.

• A consultation with a vascular surgeon may be required, especially when an underlying surgically correctable vascular abnormality is suspected.
• A consultation with a hematologist may be needed when treating a patient with stasis dermatitis due to deep venous thrombosis; cases such as these may be secondary to congenital or acquired hypercoagulable states.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Recent new theories regarding the pathogenesis of cutaneous inflammation in venous insufficiency have led to the investigation of systemic therapies, which have been hypothesized to have beneficial modulating effects on neutrophil function. Treatments, such as prostaglandin E1 (PGE1) and pentoxifylline, have been studied in the treatment of venous ulcers; it is hypothesized that these medications decrease cytokine-mediated neutrophil activation, leading to reduced inflammation. However, even if these systemic therapies are proven unequivocally effective, it is unlikely that their use will extend beyond the scope of treatment of recalcitrant venous ulcers.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Further Outpatient Care

• Stasis dermatitis is a chronic condition. Acute exacerbations of stasis dermatitis should be closely monitored with weekly office visits with careful observation for signs of infection.
• Patients with long-standing stasis dermatitis may be able to manage the disease on their own, with the use of compression stockings, elevation, proper skin care, and short courses of topical steroids for inflammatory exacerbations.
• The clinician must be vigilant in treating any signs of cutaneous ulceration with close follow-up care to ensure that ulceration does not become a chronic problem.

Complications

• Complications of chronic stasis dermatitis include cellulitis and nonhealing venous ulcers.
• Direct consequences of stasis dermatitis include an increased incidence of allergic contact dermatitis, lower-extremity ulceration, lipodermatosclerosis, and id reaction (autoeczematization).

Patient Education

• Patients should be educated regarding the underlying cause of their condition and the permanent nature of venous valvular insufficiency.
• For excellent patient education resources, visit eMedicine's Skin, Hair, and Nails Center and Circulatory Problems Center. Also, see eMedicine's patient education articles Eczema and Blood Clot in the Legs.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  This patient with chronic stasis dermatitis exhibits classic features, such as erythema, hyperpigmentation, and dilated superficial veins reflecting poor function of the deep venous system. The condition is typically confined to the lower leg, particularly the medial portion of the leg.
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Media type:  Photo

Media file 2:  In this patient with stasis dermatitis, note the large scar on the calf that was caused by military shrapnel. Injuries to the venous system due to trauma or surgery are common factors that contribute to the development of stasis dermatitis.
	View Full Size Image
Media type:  Photo

Media file 3:  This patient exhibits the dermal sclerosis and hyperpigmentation typical of chronic stasis dermatitis. In addition, the patient has developed a venous ulcer, which is a common complication of stasis dermatitis.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

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Article Last Updated: Feb 26, 2007