Answer: D

Stasis dermatitis, or venous eczema, is an inflammatory skin pathology that develops as a result of impaired venous drainage, most commonly in the lower limbs. Often associated with peripheral pitting edema, varicose veins, and in later stages lipodermatosclerosis and ulceration, it is a concerning and debilitating condition for many older patients.9 Stasis dermatitis has been discussed in literature for several decades, particularly in relation to venous insufficiency, development of venous stasis ulcers, and its proposed propensity for increased contact sensitization.

Stasis dermatitis occurs primarily in elderly patients, as it stems from chronic venous insufficiency that occurs at an increased rate in this population. Approximately 6.2% of individuals aged ≥65 years have been found to have chronic venous insufficiency.10,11 With advanced chronic venous insufficiency, skin findings such as stasis dermatitis and skin ulcers develop, affecting an estimated 2 to 6 million people.12 In addition to older age, other risk factors for stasis dermatitis include obesity, female gender, pregnancy, occupations involving prolonged standing, and family history of venous disease.11


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The etiology of stasis dermatitis centers on chronic venous insufficiency, which is principally caused by venous hypertension. Venous hypertension results from incompetent venous valves, valve reflux, venous outflow obstruction, and failure of the skeletal muscle pump due to prolonged immobility or obesity, all leading to impaired venous flow and a rise in venous pressure.13 Increased pressure in the venous system causes movement of fluid from the vascular space to the interstitium, leading to pitting edema in the affected extremities. Edema and subsequent activation of the inflammatory cascade for prolonged periods of time lead to skin manifestations such as stasis dermatitis and venous ulcers.13

Clinical features of stasis dermatitis include erythema, scaling, lichenification, and formation of plaques and papules, in addition to the pitting edema and prominent superficial veins that result from the underlying venous insufficiency.9,14 Hyperpigmentation often develops in these patients as well, likely from hemosiderin deposition. Patients most frequently complain of aching, itching, cramps, and a feeling of heaviness, coinciding with symptoms associated with chronic venous insufficiency.14 If left untreated, patients may develop venous ulcers, typically at the medial malleolus, or lipodermatosclerosis.9,15 Patients may also experience increased contact sensitization, frequently to topical drugs and dressings commonly used in treatment, including antiseptics, corticosteroids, and antibiotics.16 This can make treatment of stasis dermatitis and venous stasis ulcers more challenging as patients may develop contact dermatitis concurrently with their stasis dermatitis.

Histologic characterization of stasis dermatitis includes extravasated erythrocytes, perivascular lymphocytic infiltrates, dermal fibrosis, and small blood vessel proliferation, which may lead to formation of discrete papules due to the inflammatory process.17,18 Nonspecific findings including hyperkeratosis, parakeratosis, acanthosis, and spongiosis are also commonly observed. Although the hyperpigmentation of chronic venous insufficiency has historically been attributed to hemosiderin deposition from these extravasated erythrocytes, some studies suggest the cause may actually be hypermelanization.19

Diagnosis of stasis dermatitis is clinical and is made by evaluation of the characteristic poorly demarcated erythematous rash with other typical features including plaques, scaling, hyperpigmentation, and edema. When diagnosis is uncertain, duplex ultrasound of venous valves can be performed to show the venous reflux or incompetent valves that contribute to this pathology.9 The differential diagnosis for stasis dermatitis includes lower limb cellulitis, psoriasis, allergic contact or irritant dermatitis, pigmented purpuric dermatoses, and in some cases where stasis dermatitis presents with solitary lesions, neoplastic processes, as well.9,15,20

The focus of treatment is relieving venous stasis, principally by compressive therapy. Skin care treatments for stasis dermatitis — including non-soap cleansers, emollients, and barrier preparations — are also beneficial.9 Topical antiseptics and ointments containing perfumes should be avoided, as patients with stasis dermatitis are at increased risk for contact sensitization.16 Pharmacologic therapy is another option, with venoactive drugs working to increase venous tone and lymphatic drainage and improve symptoms of venous insufficiency.9 Surgical management of the underlying venous reflux is the backbone of treatment; former open surgical methods of saphenofemoral junction ligation has been replaced by less-invasive techniques, including endovenous thermal ablation and ambulatory phlebectomy.9

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Prognosis depends on the progression of stasis dermatitis and severity of the underlying venous insufficiency. With early diagnosis and proper use of compression stockings or with surgical intervention to address the venous insufficiency, outcomes may be improved and patients are less likely to progress to having skin manifestations such as stasis dermatitis and associated sequelae. With the increasing aging population, chronic venous insufficiency and later development of stasis dermatitis will likely become an increasingly common problem encountered in clinical practice; therefore, early intervention and management is a key step in lessening the burden of this skin pathology.

The patient in the case described above elected to treat her condition with topical petrolatum and compression stockings.

Maya Firsowicz, BS, is a medical student; Claire J. Wiggins, BS, is a medical student; and Christopher Rizk, MD, is a dermatology fellow at Baylor College of Medicine in Houston, Texas.

References

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