Venous Stasis Dermatitis

1. Venous Stasis Dermatitis Kenneth T. Kircher, DO FAOCD Advanced Dermatology, PLLC

5. Stasis Dermatitis (SD) • An inflammatory process (eczematous) • Acute, subacute or chronic • Occurs on lower legs • Setting of venous insufficiency(VI) • Poor flow of venous and lymphatic fluid from the legs and feet to the central circulation • Many contributing factors • May be accompanied by ulceration

6. Anatomy and Physiology • Three types of vessels • Arteries – high pressure, muscular wall • Veins – low pressure, check valves, thin wall • Lymphatics – low pressure, check valves, very thin wall • The problem – humans are bipedal / gravity • Veins and lymphatics rely on the pulsatile nature of arteries and the compressive action of muscle contraction to keep fluid moving up hill from check valve to check valve

8. Disruption of Homeostatic Balance • Damage to veins and/or lymphatics • DVT, damage to valves/varicosities, trauma, DM • Medications • Calcium channel blockers • Age related / social • Immobility, sedentary, sleeping in a chair • Total body fluid over load • CHF, renal failure, thyroid disease, others

9. Role of Venous Insufficiency (VI) • Rarely purely venous or lymphatic • Pooling of the blood in the veins • Increases the hydrostatic pressure • Fluid component of blood leaks into surrounding tissue causing edema (+/-pitting) • There is a decrease in the O2 tension in tissue • Many factors precipitate inflammation (fibrin) • Cells of the skin are less healthy (in a milleu of increased waste and lower O2)

10. Moderate edema with mild stasis changes

11. Finally… Stasis Dermatitis • VI causes inflammation in the skin and soft tissue • Compromised skin more susceptible to drying, irritation and trauma • Micro breaks - increased allergy to topical agents • ? Allergic response to an epidermal protein • Created from increased hydrostatic pressure

12. Allergy to Topical Agents • More likely to have a positive patch test to topical products • Common allergens • Lanolin, benzocaine, parabens, neomycin, bacitracin (these should be avoided) • Possible topical steroid allergy

13. Stages of Eczematous Inflammation • Acute, subacute and chronic • Do not have to develop in order • Different clinical appearances

14. Acute Inflammation • Tends to be more sudden in onset • May mimic cellulitis • Boggy, +/-vesicle formation (poison ivy) • Often weeps and crusts (yellowish serous exudate) • May be accompanied by Id reaction • eczematous rash with +/-vesicles on a distant body site

15. Acute on mild chronic changes

16. Acute with chronic changes including depressed scars

17. Subacute Inflammation • More prolonged, insidious in onset • Tends to be dryer, red, scaling • Scale may be significant (suggesting longer duration) • Most commonly seen in winter months with increasing dryness

18. Subacute

19. Subacute to chronic with excoriations

20. Chronic Inflammation • Tends to be thicker, lichenified (accentuation of the skin lines, thickening of the skin, may have thick scale) • Skin may have a cobblestoned texture • Results from long standing inflammation and often chronic scratching • Not the same as chronic stasis changes

21. Severe chronic dermatitis with hyperkeratosis

22. Chronic dermatitis with fibrosis and hyperkeratosis

23. Chronic SD Changes • Due to repeated flares and long standing VI • Most common over the medial lower leg/ankle • Skin becomes diffusely hyper-pigmented (hemosiderin deposition), may be thickened or atrophied with smooth shiny surface • Scarring and fibrosis may present with hypo-pigmentation and avascuarization • Atrophie blanche, inverted champagne bottle

25. Moderate stasis changes

26. Chronic stasis changes showing lipodermatosclerosis changes (inverted champagne bottle)

27. Chronic stasis changes with vascular thrombosis

28. Chronic changes with ulcer

29. Ulcers • Primarily occur on medial lower extremity • Thought to be due to venous reflux of perforating veins • May lead to increased fibrin deposition and increased fibrosis of skin • Tend to be shallow, painful or minimally painful, in a setting chronic VI changes, scarring, atrophie blanche

30. Ulcers - When To Biopsy • Not responding to therapy (carefully measure) • Very long standing • Unusual appearance • Unsure of diagnosis • DDx of Ulcers – arterial, neuropathic, infectious, immunologic, neoplastic, hematologic, infestations

31. Typical Clinical Course • Pts have a history of mild swelling of lower legs • Begins in 30’s or 40’s or after child birth, a surgical procedure, DVT, trauma, weight gain and others • Swelling gradually worsens over time • Is exacerbated by high salt intake, prolonged standing it is worse at night and better in the morning

32. Clinical Course Continued • Legs get dry especially in winter • Severe flares with burning itch are more common (acute on chronic inflammation) • The color of the lower legs slowly changes darkening becoming chronically red brown • Tissue becomes fibrosed or bound down feeling, areas of scar may appear • Ulcers begin medially, healing slowly

33. History • How severe • Only in evening, gone in morning, all the time, drainage, history of ulcer • Symptoms • Burn, itch, fatigue, pain • Prior treatment • What are they applying (creams, topical antibiotics, peroxide etc)

34. History • Review past medial history • CHF, DM, neuropathy, DVT, trauma (surgery), varicosities, arthritis, poor mobility, protein loss • Medications • Calcium channel blockers, diuretics- compliance • How long have they had swelling • If recent, prolonged sitting or immobilization, pain in calf, unilateral or bilateral • Social • Do they sleep in a flat bed or sitting in a chair

35. Physical Exam • General exam • Pulmonary exam, cardiac exam as indicated • Pitting edema • +1 – 4 (subjective but I use 1 ~ slight, 2 ~ ¼ to ½ inch, 3 ~ ½ to ¾ inch, 4 ~> ¾ inch) • How high does it go? (mid shin, knee, thigh) • Does it appear to be on the verge of vesiculation or ulcer? • Varicosities?

36. Physical Exam Continued • Chronic stasis changes • Pigment changes, atrophie blanche, ulcer scars • Is it hot, cool, tender • Evidence of neuropathy (touch toes and sole or nylon bristle) • Check pulses (may be hard to feel with severe edema), capillary refill • Check both legs

37. Treatment of SD • Treat underlying disease • Venous reflux, CHF • Treat the underlying cause – blood is pooling in the TISSUE of the lower leg • ***The bulk of fluid is in the tissue but the patient may be intravascularlyeuvolemic*** • Treat the inflammation • Reduce the inflammation and repair the skin

38. Treat ‘Tissue’ Fluid Overload • Compression and elevation – most important • Compression hose – knee high is usually OK • Mild (Class I) 20 - 30 mm Hg • Moderate (Class II) 30 – 40 mm Hg • Severe (Class III) 40 – 50 or even 60 mm Hg • Need to be Mod to be covered by ins • Hard to get on, uncomfortable, hard to manage especially if arthritis, poor mobility, elderly

39. After two days of ACE wrap

40. Treating ‘Tissue’ Fluid Overload • Compliance – always an issue • Tubey grips • Elastic stocking that comes in 3 sizes, Rx to fold over in a double layer, pts have to be measured • OTC Hose • Light, easier to get on, less uncomfortable , come in colors • Wearing less effective hose is more effective than not wearing more effective hose

41. Treating ‘Tissue’ Fluid Overload • Elevation • Reversing the venous pooling of blood and aids in lymphatic drainage • Feet should be above the buttocks • Recliners are great (ask where they sleep) • Elevate bottom 1/3 of mattress with news print or suit case or foam wedge (under the mattress) to a height of 3 - 5 inches (‘no leg on a pillow’)

42. Treating ‘Tissue’ Fluid Overload • ***Diruetics*** • Decrease the intravascular volume, but most of the fluid is extravascular, so… though helpful in fluid overload (CHF) they alone are NOT THE ANSWER • Many patients on diuretics have a decreased intravascular volume and persistent edema

43. Unna Boot • A zinc oxide impregnated gauze, covered with cotton cling and then a double layer of coban • Applied in the office and left on 3 – 7 days. • Covers skin with a moist and soothing dressing • Zinc is a cofactor in wound healing • Supplies compression • Takes away compliance as an issue

44. Unna Boot • How to apply • Best to apply after leg has been wrapped as to minimize edema (seldom done) • Zinc gauze is wrapped from the foot to above the calf and just below the knee • Next a thin layer of cotton cling (+/-) • Finally a layer of coban (short stretch disposable wrap), pull to full stretch and then release to 50% • ? Too tight, have the patient back in 2 – 3 hours

45. Modified Unna Boot • Apply clobetasolointment, followed by cling and coban • Good for short duration (2-4 days) • Decreases inflammation • I bill as for an Unna boot

46. The Last Thing on Unna Boots • http://www.youtube.com/watch?v=cbWkBpgu2n8&feature=related • Teach your nurse how to do it well • Coding for Unna boot • 29508 • Medicare allowable: $43.16 (Kingston region)

47. Decreasing Inflammation (‘Dermatology Part’) • Topicals • Class I or II steroid in an ointment base • Clobetasol (class I) (My ‘go to’) • Fluocinonide (Lidex) (class II) • Ointments are less likely to cause contact allergy • Apply BID for 10 – 14 days • No other topicals - except Vaseline if needed

48. Decreasing Inflammation • Systemic cortisones • Infrequently used because topicals work well and side effects • Used for Id reaction (widely distributed eczematous reaction) • Consider infection • Culture it! – especially for an odiferous or non healing ulcer • Don’t ‘jump to antibiotics’

49. Maintenance Care • Compression and elevation • Negotiate a means to maintain minimal edema • Education, education, education • Compliance , compliance, compliance – its always an issue • Skin care • Moisturize with Vaseline only • Limit steroid to 1-2 days per week, BID up to 10 days for flare

50. Ulcer Treatment • Consider culture or biopsy if NOT responding • All biopsies carry a risk of worsening the ulcer • Wound care • Avoid debridement, vaseline, non-stick dressing • Compressed with (ACE wrap, coban, hose) • Try to avoid adhesives • Diagram and measure length and widths • Treat surrounding skin