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 Symptoms Prior treatment
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 Medications
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 Pitting edema Varicosities?
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 intravascularly euvolemic***
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) 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 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 clobetasol ointment, 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
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 Skin care
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

51. Patient after 6 months at wound care

52. After two months of tubey grips 24/7 and vaseline BID

53. Case I
52 YO woman, works as a toll collector, sits on a stool or stands 8 hours a day
Swelling in legs worsening over last year, better in morning
Legs get red and are now slightly discolored
Not using moisturizer, no other topicals
Itch at times

54. Moderate edema with mild stasis changes

55. Case I Treatment Hose (education) Elevate (education)
Mild to moderate especially for prolonged standing or sitting (sell it) (OTC for compliance and esthetics)
Elevate (education)
When able, bottom 1/3 of bed… recurring dividend
Moisturize (education)
Cream or vaseline especially in winter

56. Case II
48 YO obese female with history of leg edema following child birth now with chronic swelling, stands at auto parts counter 8 hrs per day
Worsening, has swelling in morning, pain
Has not had an ulcer
Severe redness and itch at times
Uses OTC anti-itch cream, polysporin

58. Case II Treatment Hose (education) Elevation (education)
Mod compression all day maybe tubey grips HS
Elevation (education)
Over lunch, evening, bed (be realistic)
Topical (education)
Moisturize daily with Vaseline
Clobetasol Ung for flares BID up to days

59. Case III 72 YO male, DMII and arthritis
Many year history of swelling, worse now, pain, oozing at times, R > L legs
Ulcer 3 years ago, healed at wound center
Wears old hose sometimes – don’t help
Using peroxide to dry up the legs
Sleeps in a bed

60. Note cut socks

61. Case III Treatment New hose (education) Elevation (education) Topicals
Moderate (rubber gloves, cuff), OTC, tubey grips
Elevation (education)
Recliner, bed (dividend), whenever sitting
Topicals
Bathe regularly, clobetasol ointment BID for 2 weeks then vaseline daily
FU – 2 weeks (education, compliance)

62. Case IV
72 YO morbidly obese female with long standing swelling and scaling, recently worse, history of CHF takes Lasix 20 mg BID (+/-), arthritis
Leg is oozing fluid, non painful ulcer
No hose
Lives alone and sleeps sitting in a chair
No topicals

65. Case IV Treatment Hose (education) Elevation (education)
Clobetasol ung and Ace wrap today, to leave on over night and Una Boot in the AM
Elevation (education)
Recliner, bottom 1/3 of bed (be persistant)
Topicals to be addressed as per case III
Medical
? Change Lasix to 40mg QD, when?, ? Echo etc
FU 4 – 7 days, ? Visting or office nurse visit

66. Thank you !
Questions?