Venous eczema, lipodermatosclerosis and venous leg ulcers

venous eczema · varicose eczema · stasis eczema · lipodermatosclerosis · venous leg ulcer · gravitational eczema

The commonest thing mistaken for bilateral cellulitis - and the single biggest source of unnecessary antibiotics in the ED.

GPBand D

Red flags

Genuine superimposed cellulitis - unilateral deterioration, increasing pain, fever and systemic upset on a background of chronic venous change
Absent pulses or an ankle-brachial pressure index that has not been checked before compression - compression bandaging on an arterial leg causes tissue loss
An ulcer with rolled or everted edges, or one that is not healing as expected - consider malignancy and the need for biopsy
Sudden unilateral swelling and pain - exclude deep vein thrombosis
Rapidly progressive pain out of proportion - necrotising infection can arise in a chronically damaged leg

Recognise

On light skin

Red-brown discolouration with haemosiderin staining, scaling, itch and oedema over the gaiter area; lipodermatosclerosis produces a hard, tight, indurated 'inverted champagne bottle' leg.

On brown and black skin

Haemosiderin staining is described as red-brown and is far less distinguishable against brown and black skin, where it merges with the surrounding tone - so the most recognisable feature of the condition disappears. Rely on the structure and the symmetry: bilateral involvement, oedema, the woody induration of lipodermatosclerosis, the inverted champagne bottle shape, varicosities, and scaling with itch rather than pain. Palpate both legs and compare. This matters more here than almost anywhere else in the atlas, because the alternative diagnosis is cellulitis, and a patient with dark skin and bilateral venous disease is at real risk of repeated courses of antibiotics for an infection they do not have. Post-inflammatory hyperpigmentation compounds the confusion further.

In any skin tone

Bilateral - true cellulitis is almost always unilateral, and this is the most useful discriminator in the whole entry
Itchy rather than painful - cellulitis hurts
Chronic, with a history over months or years, rather than an acute onset over hours or days
Oedema, varicosities, haemosiderin change and scaling
Lipodermatosclerosis: hard, tight, tender, indurated skin with the leg narrowing above the ankle
Usually afebrile with normal inflammatory markers - but a normal CRP does not exclude cellulitis, particularly early disease, or in an older or immunosuppressed patient

Distribution

Lower legs, particularly the gaiter area above the medial malleolus. Characteristically bilateral, though often asymmetrical in severity.

Photographs

Venous eczema over both gaiter areas. Scaly, crusted, inflamed skin running up the inner calf, on a background of brown haemosiderin stainin — Venous eczema over both gaiter areas. Scaly, crusted, inflamed skin running up the inner calf, on a background of **brown haemosiderin staining** from chronic venous hypertension. Two things argue against cellulitis, which this is constantly mistaken for: it is **bilateral and symmetrical**, and the patient is systemically well. Bilateral lower-leg 'cellulitis' is almost always venous eczema, and treating it with antibiotics instead of emollient and compression is one of the commonest errors in the ED. The only openly licensed photograph found for this entry shows light skin. **That is a limitation of this page, not of the disease** - a darker-skin photograph is still being sought.
Fitzpatrick II (Fitzpatrick type estimated from the photograph, not stated by the source) · Commons user Cardiologist61 (PD-self) · Wikimedia Commons - Stasis dermatitis (Gravitational eczema).jpg · Public domain

Provenance for every photograph in this library: image licences. How much of the corpus still has no darker-skin photograph: skin tone coverage.

Mimics

Cellulitis — The key distinction. Cellulitis is unilateral, acute, painful and often febrile; venous eczema is bilateral, chronic and itchy. Bilateral lower-limb cellulitis is rare
Contact dermatitis - allergic and irritant — Contact allergy to bandages, dressings or topical antibiotics is very common in this group and perpetuates the eczema
Necrotising fasciitis and necrotising soft tissue infection — Disproportionate pain on a chronically damaged leg still means escalate
Atopic eczema and infected eczema — Venous eczema is a distinct pattern driven by venous hypertension, not atopy
Diabetic foot ulcer and deep-seated foot infection — Venous ulcers sit in the gaiter area and are usually painful; neuropathic ulcers sit on plantar pressure points and are usually painless - and the diabetic foot has a one-working-day referral clock

What to do in the ED

Ask whether this is actually infection. Bilateral, itchy, chronic and afebrile is usually venous disease rather than cellulitis, and antibiotics will not help that. Then look separately for infection superimposed on one leg - CKS lists infection among the complications of venous disease and asks you to assess for it, so it coexists with the venous pattern rather than being excluded by it
Emollient generously and a topical corticosteroid for the eczematous component
Check the arterial supply before anyone applies compression - an ankle-brachial pressure index is needed, and compression on an arterial leg is harmful
Arrange compression therapy and leg-ulcer service referral where there is an ulcer, since compression is the definitive treatment for venous ulceration
Elevate the leg and advise on elevation and mobility at home - this treats the underlying cause
Consider a contact allergy to dressings or topical preparations in eczema that is not settling, and refer for patch testing
Refer for venous assessment, since treating the underlying venous incompetence reduces recurrence

Disposition

Topical treatment, elevation and referral to community leg-ulcer or tissue viability services. Admit only for genuine superimposed infection, suspected DVT or critical limb ischaemia.

Safety-netting

This is a problem with the veins rather than an infection, so antibiotics will not help it and are not the treatment. Keep the leg raised whenever you sit, and keep using the emollient. Return if one leg alone becomes suddenly more swollen, hot and painful, if you develop a fever, if an ulcer appears or an existing one grows, or if the pain becomes severe. Do not apply compression bandaging until the circulation to your leg has been checked.

Local variation

Leg-ulcer and tissue viability service structures differ substantially between areas, as does who performs the ankle-brachial pressure index.

Sources

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