Venous Stasis


Key Points

  • Chronic venous insufficiency stems from the acquired incompetence of venous valves that prevent retrograde blood flow through the venous system, resulting in complications, including edema, prominent veins, stasis dermatitis, and ulcers.
  • Stasis dermatitis and leg ulcers are common complications of chronic venous insufficiency.
  • Stasis dermatitis is usually very responsive to topical corticosteroids and compression. Consistent use of compression plays an important role in the prevention of subsequent recurrences.
  • An important diagnostic consideration in the management of stasis dermatitis is lower extremity cellulitis. Cellulitis is typically unilateral, whereas stasis dermatitis is classically bilateral. Cellulitis is commonly accompanied by signs of systemic infection, such as fever and leukocytosis (whereas stasis dermatitis is not).
  • Sixty percent of leg ulcers are due to venous insufficiency, and 30% more are associated with a combination of arterial and venous insufficiency. The medical treatment of leg ulcers due to venous insufficiency requires the consideration of important differential diagnoses of leg ulcers, management of leg edema, monitoring for wound infection, and proper wound care.

Introduction

Chronic venous insufficiency stems from the acquired incompetence of venous valves that prevent retrograde blood flow through the venous system, resulting in complications, including edema, prominent veins, stasis dermatitis, and ulcers. Valvular incompetence may result from surgical or accidental trauma and genetic factors. Early signs of chronic venous insufficiency include the development of prominent telangiectatic (aka spider) and reticular veins, venous blebs, and lower extremity edema. Later signs of chronic venous insufficiency are a characteristic brawny golden discoloration and/or sclerotic induration of affected skin. The distribution may be asymmetric, with the left leg more commonly affected versus the right leg.

Stasis dermatitis is an intermittent condition that progressively evolves from chronic venous insufficiency. It is characterized by a pruritic eczematous eruption overlying areas of chronic venous insufficiency. These areas may be highly prone to developing allergic contact dermatitis to topical medications used to treat the recurrent eruption. It is usually very responsive to topical corticosteroids and compression. Consistent use of compression plays an important role in the prevention of subsequent recurrences. An important diagnostic consideration in the management of stasis dermatitis is lower extremity cellulitis. Cellulitis is typically unilateral, whereas stasis dermatitis is classically bilateral. Cellulitis is commonly accompanied by signs of systemic infection, such as fever and leukocytosis (whereas stasis dermatitis is not).

Sixty percent of leg ulcers are due to venous insufficiency, and 30% more are associated with a combination of arterial and venous insufficiency. They may become chronic wounds, and barriers to effective wound healing include ongoing edema (if compression is not incorporated into the wound care), infection, and poor arterial vascular supply to the area. The medical treatment of leg ulcers due to venous insufficiency requires the consideration of important differential diagnoses of leg ulcers, management of leg edema, monitoring for wound infection, and proper wound care.

Initial Evaluation

Differential diagnosis

Necrobiosis lipoidica

Leukocytoclastic vasculitis

Cellulitis

Note: Cellulitis tends to be unilateral, not bilateral, and is accompanied by signs of systemic infection, such as fever and leukocytosis.

Treatment

Stasis dermatitis

First-line therapy: The first-line therapy for stasis dermatitis includes control of edema, if possible, and use of an anti-inflammatory topical medication such as a medium potency topical corticosteroid.

Stasis dermatitis typically appears above the medial malleolus. It is complicated by xerosis and allergic contact dermatitis in many cases.

First steps

  • Managing edema: Prescribe elastic stockings of at least 30 mm Hg to firmly but gently compress the extremity.
  • Patient counseling regarding edema management is important. Recommend that the patients elevate the lower extremity by raising the foot above the level of the heart while sitting or lying down; discourage long periods of standing; and encourage brief exercises-when possible-such as flexion and extension of the calf muscles or walking to facilitate venous return to the heart.
  • Prescribe a medium potency topical corticosteroid medication, such as triamcinolone 0.1% cream or ointment, twice daily to the stasis dermatitis. Compression stockings may be worn after steroid application. Expect resolution of dermatitis in 7-14 days.
  • If the patient fails to respond after 48-72 hours, is febrile, or has an elevated white blood cell count, hospitalize the patient, culture the blood, and treat the patient with intravenous antibiotics to provide coverage for staphylococcal and streptococcal cellulitis.

Subsequent steps

  • Continue compression and elevation therapy.
  • Xerosis or superficial desquamation frequently follows stasis dermatitis; apply an emollient regularly as needed.

Alternative steps

  • Control of edema by simple physical measures may not be possible in some individuals. For such patients consider evaluation for another cause of the persistent edema (cardiac, hepatic, or renal disease).

Pitfalls

  • Peripheral edema may be caused by mechanisms other than venous insufficiency. Consider congestive heart failure, lymphatic obstruction (cancer), renal failure, or hepatic disease.
  • Dermatitis may be from contact dermatitis rather than stasis; it is important to note that patients with stasis dermatitis commonly develop allergic contact dermatitis to topical medications or other contactants in the areas affected by stasis. Patients may have used topical preparations containing lanolin, parabens, ethylenediamine, neomycin, or other sensitizers. An adequate history and appropriate patch testing are keys to confirming this diagnosis.

Ulcerations due to chronic venous insufficiency

First-line therapy: The first-line therapy for leg ulcers caused by chronic venous insufficiency includes the consideration of important differential diagnoses of leg ulcers, management of leg edema, monitoring for wound infection, and proper wound care.

Stasis ulcers are the most common cause of leg ulceration. Evidence of venous insufficiency may be minimal, so in some cases vascular evaluation (by Doppler ultrasound) may be required to confirm venous insufficiency as the etiology of the leg ulcer. In all ulcerations, if appropriate and progressive healing does not occur, a biopsy is indicated. Patients with a tendency to low leg ulcerations may have inherited or acquired defects in their fibrinolytic systems. Appropriate evaluation for these conditions is indicated, especially if there is a history of prior venous thrombosis. Arterial insufficiency may coexist. Determining the ratio of the diastolic blood pressure in the leg versus. the arm (ankle-brachial index, or ABI) is recommended in all patients, as standard methods for healing venous ulcerations may be ineffective in the presence of significant arterial disease. (Arterial insufficiency is suggested when the ABI is <0.5-0.7.)

First steps

  • Control edema and dermatitis as described above. Control of edema is essential to improvement of the leg ulcer.
  • Monitor and treat for infection: Excessive drainage, surrounding erythema, tenderness, and failure of a healing ulcer to continue to heal may be signs of infection. Wound cultures are recommended and appropriate antibiotic therapy should be given. Note: Most leg ulcers will be colonized with bacteria, so finding bacteria by culture does not diagnose “infection.” Cultures of leg ulcers are only of value if they are obtained in the setting of clinical findings of infection. The presence of infection is confirmed if treatment for infection improves the patient’s symptoms and the appearance of the ulcer.
  • Debride the ulcer: If there is firm adherent fibrinous exudate in the ulcer, debridement will accelerate healing. Apply 30% lidocaine in acid mantle base and wait 20 minutes before gently debriding with a curette. This can be repeated at each clinic visit until all necrotic debris has been removed from the ulcer bed.
  • Daily wound care: If possible, daily cleansing with saline or soap and water with application of a fresh wound dressing is ideal. Apply a multilayered dressing: petrolatum or an antimicrobial medication at the wound base, petrolatum-impregnated gauze or a non-stick dressing, gauze dressing, with a final wrap with a gentle elasticized bandage to create compression (if there is no component of arterial insufficiency).
  • If daily wound care is not possible, cleanse/change on a weekly basis in the clinic or wound care facility. A typical weekly dressing would include some of the following:
  • Topical metronidazole or other antimicrobial medication to control bacterial overgrowth.
  • Becaplermin to stimulate granulation tissue (in slowly responding ulcers).
  • Desiccated animal collagen (xenograft) if needed to accelerate wound healing (in slowly responding ulcers).
  • Semipermeable dressing over the whole ulceration, sealed at the periphery.

For exudative wounds, fenestrated dressings, or superabsorptive ones, may be used. Unna boot wrap of the whole leg from toes to just below the knee. The final wrap-if no component of arterial insufficiency is present-should be an application of Coban dressing to apply appropriate pressure (30 to 40 mm Hg). On a weekly basis, measure the ulcer (to document improvement), gently clean and debride the ulcer bed and reapply dressings.

Ancillary steps

  • If the ulcer is exudative or foul smelling, it is usually due to overgrowth by anaerobic bacteria. Apply metronidazole gel 0.75% into the ulcer bed before applying the dressing to control bacterial overgrowth.
  • Pentoxyphylline 400 mg 3 times daily may result in more rapid healing of venous stasis ulceration.
  • Venous ulcers can be very painful. Usually the pain resolves once a granulating base is formed. Provide adequate oral analgesia and monitor the severity of the pain. Often pain reduction parallels or precedes ulcer healing.

Subsequent steps

  • After the ulcer heals, carefully continue the program of edema control. Support hose with at least 30 mm Hg compression are essential for all patients with healed leg ulcers.
  • If the ulceration fails to heal, cultured human keratinocyte or human skin equivalent grafting can be considered. These grafts are not permanent but are effective in converting non-healing leg ulcers into healing ones. They are also very effective in pain control.

Pitfalls

  • A non-healing ulcer may be cutaneous carcinoma (basal cell, squamous cell, etc.) or an inflammatory ulcer (such as pyoderma gangrenosum). Biopsy non-healing ulcerations after three months of treatment or if there is concern for an alternative diagnosis.
  • The topical antibiotics bacitracin and neomycin should not be applied to leg ulcers due to the high risk for allergic contact dermatitis.
  • Oral antibiotics are overused in the management of leg ulcers. Many “exudative” ulcers represent appropriate exudation indicative of the early phase of wound healing. This will resolve over a few weeks as the ulcer bed is replaced with granulation tissue. Highly exudative ulcers may benefit from daily treatment with a drying compress (such as Burow’s soak) and use of a highly absorptive wound dressing to avoid maceration of the wound base.
  • Any ulceration that is deep and fails to heal or that develops an undermined “pocket” at one edge should be evaluated for underlying osteomyelitis with an appropriate radiological studies.
  • If arterial insufficiency coexists (especially ABI <0.7), vascular surgical intervention may be required before the ulcer will heal.
  • Non-healing venous insufficiency ulcerations frequently occur after surgeries for skin cancers below the knee in elderly persons. Before surgery in elderly persons, perform an ABI and evaluate the patient for venous insufficiency. If significant venous insufficiency exists, consider wrapping the extremity with a support wrap (as outlined above) during the post-surgical period.
  • Cholesterol emboli, sickle cell disease, polyarteritis nodosa, Buerger’s disease, cocaine use, and antiphospholipid antibody syndrome may all cause lower leg ulcerations. If the ulcer is atypical or fails to heal, consider appropriate evaluation.

When to refer to a dermatologist

  • If the diagnosis of venous stasis dermatitis is not clear.
  • If there is a concern for allergic contact dermatitis, especially in the setting of using topical medications for stasis dermatitis.
  • If there is a concern for a non-stasis related ulceration, such as pyoderma gangrenosum, or concern for an evolving non-melanoma skin cancer in a chronic leg ulcer.

Clinical Cases

Case 1

  • 63-year-old female
  • Past medical history is notable for hypertension
  • Review of systems is noncontributory
  • Presents for management of 3-year history of varicose veins, bilateral lower extremity swelling, and recurrent rashes on the ankles
  • Does not wear compression stocking

Evaluation and management

  • Healthy appearing woman
  • Bilateral lower extremities (left greater than right) with mild pitting edema to the ankles, prominent varicose veins, brawny and slightly purpuric hyperpigmentation overlying the medial malleolus
  • Normal sensory and motor testing of the legs
  • Strong, symmetric pedal pulses
  • No evidence of rash or ulceration
  • Diagnosis: venous stasis with likely intermittent stasis dermatitis
  • Recommend compression stockings, used daily (30 mg Hg pressure)
  • Daily use of hypoallergenic emollients
  • Topical triamcinolone 0.1% ointment applied BID as needed when rash recurs
  • Follow-up every 3 to 6 months

Case 2

  • 76-year-old healthy man
  • Past medical history notable for chronic venous insufficiency, mild diabetes mellitus, hypertension, lower back pain
  • Review of systems is noncontributory
  • Presents for management of 7 weeks’ history of a non-healing ulceration on the medial malleolus
  • Wound care with a small bandage overlying only
  • Does not use compression stockings

Initial evaluation

  • Healthy appearing male
  • Bilateral lower extremity edema, varicose veins and vascular blebs, brawny hyperpigmentation, xerotic changes, with a 1.4 x 2.6 cm ulceration overlying the left medial malleolus
  • No evidence of superinfection is present
  • Normal sensory and motor testing of the legs
  • Strong, symmetric pedal pulses
  • Diagnosis: venous stasis ulceration
  • Recommend weekly wound care changes in the clinic; the ulceration is measured and then cleansed with dilute soap and water wash; the wound dressing: petrolatum ointment, non-stick bandage, gauze, Unna bandaging, elastic bandage as the final wrap. The patient is instructed that this bandage is to be changed once a week in the clinic only. A compression stocking is prescribed for use on the other leg.
  • Follow-up in 7 days

Follow-up evaluation

  • The ulceration is measured (1.2 x 2 cm) and then cleansed with dilute soap and water wash. There is no evidence of wound superinfection and the area of venous stasis dermatitis surrounding the ulcer appears much improved. The wound dressing is re-applied.
  • Follow-up in 1 week (patient required 8 weeks of weekly bandage changes for full re-epithelialization of the leg ulcer)

References

http://www.gmpublichealthpracticeunit.nhs.uk/wp-content/uploads/2010/12/Lower-limb-chronic-venous-insufficiency-including-Varicose-Veins-Referral-Recommendations.pdf

Bailey E, Kroshinsky D. (2011) Cellulitis: diagnosis and management, Dermatol Ther, 24(2): 229-239.

Prakash AV, Davis MD. (2010) Contact dermatitis in older adults: a review of the literature, Am J Clin Dermatol, 11(6): 373-381.