Varicose eczema

Definition
Varicose eczema (also called stasis dermatitis or gravitational eczema) is a chronic inflammatory skin condition of the lower legs that occurs as a manifestation of chronic venous insufficiency. It is often associated with varicose veins, venous hypertension, and other venous skin changes.

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Causes and Pathophysiology

• Underlying cause: Chronic venous insufficiency → venous hypertension → leakage of fluid, proteins, and red blood cells into skin → inflammation

• Mechanism:

  • Venous valve incompetence or obstruction leads to prolonged high pressure in superficial and deep veins

  • Capillary leakage results in oedema, fibrin deposition, and inflammatory mediator release

  • Long-term inflammation damages skin barrier and elasticity

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Risk Factors

• Varicose veins

• History of deep vein thrombosis (post-thrombotic syndrome)

• Obesity

• Pregnancy (repeated or prolonged)

• Age >50 years

• Sedentary lifestyle or prolonged standing

• Previous leg injury or surgery affecting veins

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Clinical Features

• Location: Lower legs, especially around the medial malleolus (“gaiter area”)

• Appearance:

  • Red, scaly, itchy patches

  • Brownish discolouration from haemosiderin deposition

  • Thickened, dry skin (lichenification) from chronic scratching

  • Possible oozing, crusting, or blistering in acute flares

• Associated signs:

  • Oedema (worse at end of day)

  • Varicose veins

  • Lipodermatosclerosis (fibrosing skin change with “inverted champagne bottle” leg shape)

  • Atrophie blanche (white scar-like patches) in advanced disease

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Complications

• Secondary bacterial infection (cellulitis, impetigo)

• Venous leg ulceration

• Contact dermatitis from dressings or creams

• Chronic skin changes leading to fragility and recurrent breakdown

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Diagnosis

• Clinical diagnosis based on characteristic appearance, distribution, and presence of underlying venous disease

• Investigations:

  • Duplex ultrasound to assess venous reflux

  • Patch testing if allergic contact dermatitis suspected

  • Swabs if infection present

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Treatment

1. Treat underlying venous insufficiency

• Compression therapy (graduated compression stockings or multilayer bandaging; check ABPI first to rule out significant arterial disease)

• Leg elevation when resting

• Regular exercise to improve calf muscle pump

• Weight management

2. Skin management

• Emollients: Liberal, frequent use to restore barrier and reduce dryness

• Topical corticosteroids:

  • Mild to moderate potency for flares (e.g., hydrocortisone 1%, betamethasone valerate 0.025–0.1%)

  • Short courses to control inflammation

• Antiseptic or antimicrobial creams if secondary infection suspected

• Avoid irritants (fragranced soaps, harsh detergents)

3. Infection management

• Oral antibiotics if cellulitis present (e.g., flucloxacillin or clarithromycin if penicillin-allergic)

4. Address complications

• Wound care for ulceration

• Patch testing for allergic contact dermatitis from creams or dressings

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Prognosis

• Chronic, relapsing condition that improves with effective venous disease management

• High risk of recurrence if underlying venous insufficiency persists

• Untreated disease can progress to venous leg ulcers