Stasis dermatitis, or stasis eczema, is a common inflammatory dermatosis of the lower extremities occurring in patients with chronic venous
insufficiency, often in association with varicose veins, dependent chronic edema, hyperpigmentation, lipodermatosclerosis, and ulcerations. Stasis dermatitis may rarely involve the upper limbs in patients with artificial arteriovenous (AV) fistulas for hemodialysis, or congenital AV malformations.
insufficiency, often in association with varicose veins, dependent chronic edema, hyperpigmentation, lipodermatosclerosis, and ulcerations. Stasis dermatitis may rarely involve the upper limbs in patients with artificial arteriovenous (AV) fistulas for hemodialysis, or congenital AV malformations.
EPIDEMIOLOGY
Skin changes related to chronic venous insufficiency, including edema, hyperpigmentation, eczema, fibrosis, atrophy, and ulceration, are reported in 1 to 20 percent of women and in 1 to 1 7 percent of men. In one study, stasis dermatitis was reported in 6.2 percent of patients over the age of 65. Established risk factors for varicose veins and chronic venous insufficiency include age, family history of venous disease, female sex, standing occupation,
obesity, and history of deep vein thrombosis. Heart failure and hypertension are aggravating factors.
obesity, and history of deep vein thrombosis. Heart failure and hypertension are aggravating factors.
PATHOPHYSIOLOGY
The final common pathway that leads to chronic venous insufficiency is the development of venous hypertension. In most cases, venous hypertension results from dysfunction of the venous valves, obstruction to the venous flow, or failure of the "venous pump". If the valves of deep or perforator veins are incompetent, the increased pressure generated during standing or calf muscle contraction causes blood to reflux into the superficial venous system, converting it into a high-pressure system. In some patients, chronic edema of the lower extremities induced by drugs may be a contributor factor in the pathogenesis of stasis dermatitis.
PATHOLOGY
Hyperkeratosis, parakeratosis, acanthosis, and mild spongiosis are the epidermal changes usually seen in uncomplicated stasis dermatitis. Spongiosis may be prominent in cases with a superimposed contact dermatitis. Dermal changes include proliferation of small blood vessels in the papillary dermis, variable dermal fibrosis, perivascular lymphocytic infiltration, extravasated erythrocytes, and hemosiderin-laden macrophages. A positive iron stain
and the evaluation of the iron deposition pattern may be helpful to confirm the diagnosis.
Signs of venous hypertension also may be seen in the dermis, including dilated capillaries with fibrin cuffs, hemosiderin deposits, and hyperplastic venules. Morphometric and ultrastructural findings include increased mast cell number, thickening of basal lamina of capillaries, and presence of transforming growth factor-beta 1 (TGF-beta 1 ). Septal involvement of the subcutaneous fat, fat
necrosis, microcyst formation, lipomembranous changes, elastosis, and calcification of adipocytes are typical features of lipodermatosclerosis.
and the evaluation of the iron deposition pattern may be helpful to confirm the diagnosis.
Signs of venous hypertension also may be seen in the dermis, including dilated capillaries with fibrin cuffs, hemosiderin deposits, and hyperplastic venules. Morphometric and ultrastructural findings include increased mast cell number, thickening of basal lamina of capillaries, and presence of transforming growth factor-beta 1 (TGF-beta 1 ). Septal involvement of the subcutaneous fat, fat
necrosis, microcyst formation, lipomembranous changes, elastosis, and calcification of adipocytes are typical features of lipodermatosclerosis.
CLINICAL PRESENTATION
Stasis dermatitis is a late manifestation of chronic venous disease (stage C4 of the Clinical Etiological Anatomical Pathological [CEAP] classification (table 2).
Stasis dermatitis typically presents with erythematous, scaling, and eczematous patches or plaques on chronically edematous legs. The medial ankle is most frequently and severely involved, although the skin changes may extend up to the knee and down to the foot. Pruritus is variable but, when present, results in lichenification from chronic scratching or rubbing. Acute forms may present with severely inflamed, weeping plaques, vesiculation, and crusting. Impetiginized
crusts and/or pustules due to bacterial or candidal superinfection may also be seen.
crusts and/or pustules due to bacterial or candidal superinfection may also be seen.
Chronic forms are characterized by hyperpigmentation, due to dermal hemosiderin deposition, scaling, and potential development of lipodermatosclerosis. Lipodermatosclerosis is a chronic form of panniculitis resulting from chronic inflammation, fat degeneration, and fibrosis. In the acute phase, lipodermatosclerosis presents with a painful erythema of the medial perimalleolar region that mimics cellulitis. However, in contrast with cellulitis, lipodermatosclerosis develops slowly, over weeks to months, and usually involves both legs. The chronic phase is characterized by hyperpigmented and indurated skin that constricts the ankle region, giving the legs an appearance of an inverted champagne bottle.
Patients with stasis dermatitis may present with other signs of chronic venous insufficiency and related comorbidities, including :
●Varicosities
●Secondary lymphedema
●Atrophie blanche (stellate, porcelain-white scarring areas resulting from microthromboses)
●Secondary cellulitis
●Ulceration
Patients with stasis dermatitis may present with other signs of chronic venous insufficiency and related comorbidities, including :
●Varicosities
●Secondary lymphedema
●Atrophie blanche (stellate, porcelain-white scarring areas resulting from microthromboses)
●Secondary cellulitis
●Ulceration
STASIS DERMATITIS SELF-CARE
Elevate your legs above the heart: Do this throughout the day. If possible, dermatologists recommend that you elevate your legs above your heart:
- Once every 2 hours for 15 minutes
- While you sleep (keep your legs elevated with pillows)
Take breaks when you must sit or stand for an hour or longer. If you must sit or stand for long periods, take a break every hour and walk briskly for 10 minutes. This will jump-start your circulation.
Get physical. Exercise can improve your circulation and strengthen your calf muscles. Walking is an especially good exercise for people who have stasis dermatitis. Be sure to build up slowly and ask your dermatologist how often you should exercise.
Wear loose-fitting cotton clothing. Wool and other rough fabrics, polyester, and rayon can irritate skin with stasis dermatitis and lead to a flare-up.
A loose fit is also important. Tight waistbands and snug pants interfere with your circulation. If clothing rubs against stasis dermatitis, the fabric can irritate the sensitive skin.
Use your compression garment if your dermatologist recommends one. Compression can:
- Improve the circulation in your legs
- Prevent open sores
- Reduce your risk of another flare
A physical therapist can offer tips for reducing the pain when you put on the garment. Most patients find that once they start wearing the compression garment, their swelling decreases within a few weeks. With less swelling, they start to feel better.
Avoid injuring the area and aggravating the stasis dermatitis. The skin with stasis dermatitis is very sensitive. If you injure or aggravate the area, it could lead to an infection or open sores.
To avoid irritating the skin with stasis dermatitis, avoid touching anything that could irritate it, such as:
- Pet hair
- Plants
- Grass
- Cleaning products
- Perfume
- Skin care products that contain fragrance (use only products labeled “fragrance-free.”)
Take care when bathing. Soaps and rough-textured towels or bath sponges can irritate skin with stasis dermatitis. Dermatologists recommend the following to their patients with stasis dermatitis:
- Use a mild, fragrance-free cleanser rather than soap. When you shower or take a bath, use only this cleanser. Rinsing soap from other parts of your body can cause the soap to run down your body, which can irritate skin with stasis dermatitis.
- After bathing, gently pat the water from your skin with a clean towel. You’ll want to keep a bit of water on the skin with stasis dermatitis.
- Within 2 minutes of bathing, apply petroleum jelly or a thick, creamy moisturizer that is fragrance-free on your damp skin. This helps to keep moisture in your skin. Keeping your skin moisturized helps to prevent scaly skin and irritation.
Reach and stay at a healthy weight. Staying at a healthy weight can reduce swelling and improve your overall health.
Drink 8 glasses of water every day. This can improve circulation and reduce swelling.
Limit salt. Too much salt can decrease your blood flow. Even if you never salt your food, you may be getting too much salt. According to the American Heart Association, the average American consumes 3,400 milligrams of sodium every day. The recommended daily amount is 1,500 milligrams or less.
Keep your dermatology appointments. Stasis dermatitis is a condition that you may have for life. Learning how to manage it and finding out what works best for you can take time. The time spent learning what to do will pay off. Most patients find that once they know what to do, they can manage the disease at home with healthy habits and medication as needed to treat flare-ups.