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Stasis Dermatitis


Presentation

Stasis dermatitis frequently presents with signs of CVI which persists regardless of the state of stasis dermatitis. This includes edema, atrophie blanche, varicosities and hyperpigmentation and reddish-brown discoloration due to deep dermal hemosiderin deposits. Most of these symptoms started in the medial ankle and gradually spread up the lower leg or down the foot. Patient may also complain of pruritis.

Along with these symptoms, patient may present with crusts, exudation and superficial ulcerations in acute cases of stasis dermatitis.

Chronically, physical examination may present with lichenification and hyperpigmentation from scratching and rubbing due to pruritis. There will also be gradual tightening of the skin as it becomes drier. Dermal fibrosis as discussed above will result to lipodermatosclerosis, scar-like changes in the fat and other soft tissues. This may also present with the classic inverted champagne appearance of the ankle.

In severe cases, ulceration occurs with oozing, crusted areas made worse with contact dermatitis and bacterial infection. Some chronic conditions develop violet plaques and nodules on the legs and dorsal foot that may undergo painful ulceration called pseudo-Kaposi sarcoma or acroangiodermatitis.

Pneumonia
  • A 76-year-old man with a history of esophageal adenocarcinoma was administered intravenous vancomycin and a combination of piperacillin and tazobactam by injection for treatment of aspiration pneumonia.[ncbi.nlm.nih.gov]
Eruptions
  • We report a case of leukaemia cutis presenting as stasis dermatitis-like eruption in a patient with myelodysplastic syndrome progressing to acute myelogenic leukaemia.[ncbi.nlm.nih.gov]
  • A patient with myelodysplastic syndrome presented with an acute eruption of bilateral, lower-extremity, tender, indurated, brown plaques that clinically resembled chronic stasis dermatitis.[ncbi.nlm.nih.gov]
  • The eruption appeared as a venous stasislike dermatitis. The temporal sequence of onset after chemotherapy administration suggested a possible drug-induced process.[ncbi.nlm.nih.gov]
  • A patient with chronic myelogenous leukemia (CML) in blast crisis experienced a peculiar painful eruption on his left lower extremity during the preterminal phase of his disease.[ncbi.nlm.nih.gov]
  • “Other eczematous eruptions: Stasis dermatitis.” In: Bologna JL, Jorizzo JL, et. al . Dermatology (second edition), Elsevier Mosby, 2008:201-2. Weaver J, Billings SD.[aad.org]
Mental Deterioration
  • Elderly people can physically and mentally deteriorate rapidly when mobility is restricted.[o-wm.com]

Workup

  • Blood Tests are only done if patient has venous thrombosis to test for hypercoagulability. They are also used if cellulitis or sepsis is suspected. 
  • Doppler Testing is used to detect for DVT or lesions from past thrombosis. It is also to assess the blood flow of new-onset acute stasis dermatitis or a young patient.
  • Patch Testing is used to test for contact allergies or skin sensitivities.
  • Skin Biopsy is rarely indicated

Acute lesions may present with:

Chronic lesions

  • Skin biopsy is necessary if necessary if patient has acroangiodermatitis (pseudo-Kaposi sarcoma). Findings are similar with biopsy of Kaposi sarcoma but with the absence of atypical endothelial cells and vascular slits.
  • Dermal fibrosis is evident by dilated dermal capillaries with intimal thickening and hyperkeratosis of stratus spinosum .
  • Aggregates of siderophages in the deep dermis due to hemosiderin uptake.

Treatment

Treatment for stasis dermatitis is more focus on the clinical effects of CVI since it directly causes the condition.

Compression therapy

Compression therapy is referred for both edema and venous ulcers. Excessive edema can delay healing and risk infection. For venous ulcers, compression therapy is coupled with bland (zinc oxide paste) or colloid-type dressings. Even after the ulcers heal, compression therapy must be continued as a lifetime habit to prevent recurrence.

Arterial function must first be assessed through physical examination or ancillary procedures. Compression therapy, a treatment for CVI leg edema, can exacerbate the patient’s condition if patient also has arterial dysfunction. Compression therapy is done through:

  • Specialized stockings or compression stockings with controlled pressure gradient as a long-term management. For venous problems, pressures of 30-40 mmHg are commonly used. Compression stocking must be put by the patient in the morning as this is when limbs are smallest with the lowest venous pressure.
  • Intermittent mechanical compression (IVC) pump and sleeve is used if patient has significant edema.
  • Unna boot provides wound cover, compression and calf pump support in pumping venous blood from the lower extremity. This treatment is best for the ambulatory.
  • Elastic wraps can be used by the patient after being trained by a professional on how to wrap them and best for non-ambulators.

Surgery

Ligation of the arteriovenous fistula or incompetent perforators can be effective if directly related to stasis dermatitis.
Varicose vein stripping is used when severe signs of stasis dermatitis such as liperdermatosclerosis, ulceration, atrophie blanche or hyperpigmentaton is present. Allogenic dermal substitutes can be used for intractable venous ulcers but are expensive and not necessary if patient responds to high-compression therapy [14]. Emergency surgery is also done if patient’s condition worsens to cellulitis to necrotizing fasciitis.

Light

Autologus platelet-rich plasma (PRP) coupled with light-emitting diode (LED) was found to be effective in treating recalcitrant ulcerating stasis dermatitis [10]. Pigmentation caused by stasis dermatitis was also found to be successfully treated with noncoherent intense pulsed light (IPL) [11].

Topical corticosteroids

Topical corticosteroids are used to alleviate pruritis and inflammation. Midpotency corticosteroids are used to avoid systemic absorption and induced cutaneous atrophy that may lead to ulceration. Tachyphylaxis is a phenomenon where the corticosteroid’s efficacy decreases due to prolonged used.
Nonsteroidal treatment do not carry the risks of corticosteroids such as cutaneous atrophy and tachyphylaxis. Calcineurin inhibitors such as tacrolimus and pimecrolimus may prove to be effective.

Topical antibiotics

Topical antibiotics are used if venous ulcers became infected. Mupirocin and silver sulfadiazine are some of the antiobiotics used. Beware of contact dermatitis caused by multiple topical medications. Any antibiotic used must first be approved by a physician. Triclosan has been shown to have low risk for contact dermatitis [12].

Oral/intravenous antibiotics

When patient acquires cellulitis, oral antibiotics are often prescribed such as cephalosporins and dicloxacillin.

Systemic therapy

The use of drugs, pentoxyfylline and flavonoids, may act on leukocyte activation and diminish the inflammatory response that leads to stasis dermatitis and venous ulceration [13]. However, even if these drugs prove to be effective, they may only be used on venous ulcer patients unresponsive to other treatments.

Prognosis

Stasis dermatitis is a chronic condition. The possibility of venous ulcer prevention and healing depend on the person’s health, age and state of CVI. If not treated properly, there would be an increase incidence of lichenification, lipodermatosclerosis, cellulitis and contact allergy dermatitis.

Etiology

Chronic venous insufficiency (CVI) causes stasis dermatitis. Valvular dysfunction of the deep venous system causes venous hypertension and blood backflow into the superficial venous system. This results to swelling and later on, skin breakdown and irritation.

Aging, deep venous thrombosis (DVT), surgery and traumatic injury can directly cause valvular dysfunction that in time would result into CVI. Other factors that can affect the lower extremity venous system are varicose veins, hypertension (HTN), kidney failure, obesity, sedentary lifestyle, drugs and hear conditions such as congestive heart failure (CHF). Female gender, pregnancy and family history of venous disease are also established risk factors [1] [2]. Amlodipine, an antihypertensive drug, can also trigger stasis dermatitis through its common side effect lower leg edema [3].

Epidemiology

The risk of stasis dermatitis also increases with age as one study shows that stasis dermatitis prevalence in 6.2% of patients over 65 years of age [4]. Another study shows that stasis dermatitis affects an estimate of 20% of people over 70 years of age [5].

In a comprehensive review in the prevalence of CVI and varicose veins, reports of CVI prevalence vary from < 1% to 40% in females and from < 1% to 17% in males. A higher prevalence of varicose veins was seen in reports varying from <1% to 73% in females and 2% to 56% in males [1]. CVI and varicose veins are more prevalent in women due to the stress pregnancy puts on the veins of the lower extremities.

Sex distribution
Age distribution

Pathophysiology

Stasis dermatitis is a direct cause of CVI. However, the mechanism behind venous insufficiency remains unclear. The most accepted theory is the fibrin cuff theory. This theory was derived in the 1970s and 1980s’ studies where it was found that increased venous hydrostatic pressure transmits to the dermal microcirculation. With the increased dermal capillary permeability, macromolecules such as fibrinogen, leak out to the pericapillary tissues.

Fibrinogen then polymerizes into fibrin which forms into a fibrin cuff around the capillaries, preventing oxygen diffusion and resulting to hypoxia and cell damage [6].

Fibrin cuffs alongside with decreased fibrinolytic activity are then hypothesized to cause dermal fibrosis, the hallmark of stasis dermatitis. Trapped activated leukocytes release not only inflammatory mediators but mediators such as transforming growth factor beta1, an important mediator for dermal fibrosis [7]. This mechanism supports a direct relationship between venous dysfuntction and cutaneous inflammation with fibrosis [8].

Chemoacttractants that keep the leukocytes active are also present in the upregulation of vascular intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) [9].

Prevention

Control of peripheral edema is helpful in the prevention of stasis dermatitis. Proper treatment is necessary to prevent complications.

Summary

Stasis dermatitis is an inflammatory cutaneous vascular disease due to chronic venous insufficiency. It is characterized by edema, erythema, pruritus and scaling of the skin. It commonly starts on the medial ankle on one or both lower extremities.

Lipodermatosclerosis, lichenification, ulceration and bacterial infection follow in severe cases. This condition is a direct consequence of chronic venous insufficiencyy (CVI) and affects women more than men aged 50 years and above.

Stasis dermatitis is also known as gravitation dermatitis, varicose eczema and congestion eczema.

Patient Information

Stasis dermatitis is skin irritation and breakdown due to fluid accumulation. Stasis causes leg swelling due to poor circulation and fluid buildup. Dermatitis is skin irritation with scaling, dryness, redness and itching.

It is caused by prolonged poor blood circulation on the veins commonly in the legs usually due to aging. This causes itching, redness, swelling and dry skin starting on the inside ankle of the foot and gradually spread to the lower leg or down the foot.

If not treated, the affected leg or foot may develop ulcers, skin hardening and discoloration which may lead to infection and hardening of tissues.

Stasis dermatitis is confirmed through physical examination and history. A blood test may be given if bacterial infection through ulcers is suspected.

Stasis dermatitis is treated by compression therapy and limb evaluation to decrease swelling. One recommended treatment is wearing of compressive stockings in the morning up to the end of the day. The compressive stocking may feel uncomfortable at first but the discomfort will lower as the edema lessens.

Skin and would care is also advised to prevent further ulceration of the leg through compression, topical medicine and wound dressing. Surgery may be prescribed in severe cases.

References

Article

  1. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfel D. The epidemiology of chronic venous insufficiency and varicose veins. Annals of Epidemiology. 2005; 15(3):175-84.
  2. Fiebig A, Krusche P, Wolf A, Krawczak M, Timm B, Nikolaus S, Frings N, Schreiber S. Heritability of chronic venous disease. Human Genetics. 2010 Jun; 127(6):669-74.
  3. Gosnell AL, Nedorost ST. Stasis dermatitis as a complication of amlodipine therapy. J Drugs Dermatol. Feb 2009; 8(2):135-7.
  4. Yalçin B, Tamer E, Toy GG, Oztaş P, Hayran M, Alli N. The prevalence of skin diseases in the elderly: analysis of 4099 geriatric patients. International Journal of Dermatology. 2006 Jun; 45(6):672-6.
  5. Nazarko L. Diagnosis and treatment of venous eczema. British Journal of Community Nursing. 2009 May;14(5):188-94.
  6. Pappas PJ, You R, Rameshwar P, et al. Dermal tissue fibrosis in patients with chronic venous insufficiency is associated with increased transforming growth factor-beta1 gene expression and protein production. Journal of Vascular Surgery. 1999; 30(6):1129-45 
  7. Peschen M, Lahaye T, Hennig B, et al. Expression of the adhesion molecules ICAM-1, VCAM-1, LFA-1 and VLA-4 in the skin is modulated in progressing stages of chronic venous insufficiency. Acta dermato-venereologica. 1999; 79(1):27-32
  8. Coleridge Smith PD, Thomas P, Scurr JH, Dormandy JA. Causes of venous ulceration: a new hypothesis. Br Med J (Clin Res Ed). Jun 18 1988;296(6638):1726-7.
  9. Peschen M, Lahaye T, Hennig B, Weyl A, Simon JC, Vanscheidt W. Expression of the adhesion molecules ICAM-1, VCAM-1, LFA-1 and VLA-4 in the skin is modulated in progressing stages of chronic venous insufficiency. Acta Derm Venereol. Jan 1999;79(1):27-32.
  10. Park KY, Kim IS, Yeo IK, Kim BJ, Kim MN. Treatment of refractory venous stasis ulcers with autologous platelet-rich plasma and light-emitting diodes: a pilot study. J Dermatolog Treat. Oct 2013;24(5):332-5.
  11. Pimentel CL, Rodriguez-Salido MJ. Pigmentation due to stasis dermatitis treated successfully with a noncoherent intense pulsed light source. Dermatol Surg. Jul 2008;34(7):950-1.
  12. Schena D, Papagrigoraki A, Girolomoni G. Sensitizing potential of triclosan and triclosan-based skin care products in patients with chronic eczema. Dermatol Ther. Oct 2008;21 Suppl 2:S35-8.
  13. Pascarella L, Schonbein GW, Bergan JJ. Microcirculation and venous ulcers: a review. Ann Vasc Surg. Nov 2005; 19(6):921-7.
  14. Taniguchi T, Amoh Y, Tanabe K, Katsuoka K, Kuroyanagi Y. Treatment of intractable skin ulcers caused by vascular insufficiency with allogeneic cultured dermal substitute: a report of eight cases. J Artif Organs. Mar 2012;15(1):77-82.

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Last updated: 2018-06-22 06:51