Venous Stasis Dermatitis Venous Stasis Dermatitis

Kenneth T. Kircher, DO FAOCDKenneth T. Kircher, DO FAOCD

Advanced Dermatology, PLLCAdvanced Dermatology, PLLC

Stasis Dermatitis (SD)Stasis Dermatitis (SD)• An inflammatory process (eczematous)An inflammatory process (eczematous)

– Acute, subacute or chronic

• Occurs on lower legsOccurs on lower legs• Setting of venous insufficiency(VI)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 ulcerationMay be accompanied by ulceration

Anatomy and PhysiologyAnatomy and Physiology• Three types of vesselsThree 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 / gravityThe 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

Disruption of Homeostatic BalanceDisruption of Homeostatic Balance

• Damage to veins and/or lymphaticsDamage to veins and/or lymphatics– DVT, damage to valves/varicosities, trauma, DM

• MedicationsMedications– Calcium channel blockers

• Age related / socialAge related / social– Immobility, sedentary, sleeping in a chair

• Total body fluid over loadTotal body fluid over load– CHF, renal failure, thyroid disease, others

Role of Venous Insufficiency (VI)Role of Venous Insufficiency (VI)

• Rarely purely venous or lymphaticRarely purely venous or lymphatic• Pooling of the blood in the veinsPooling 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)

Moderate edema with mild stasis changesModerate edema with mild stasis changes

Finally… Stasis DermatitisFinally… Stasis Dermatitis

• VI causes inflammation in the skin and soft VI causes inflammation in the skin and soft tissuetissue

• Compromised skin more susceptible to Compromised skin more susceptible to drying, irritation and traumadrying, irritation and trauma– Micro breaks - increased allergy to topical agents

• ? Allergic response to an epidermal protein? Allergic response to an epidermal protein– Created from increased hydrostatic pressure

Allergy to Topical AgentsAllergy to Topical Agents

• More likely to have a positive patch test to More likely to have a positive patch test to topical productstopical products

• Common allergens Common allergens – Lanolin, benzocaine, parabens, neomycin,

bacitracin (these should be avoided)– Possible topical steroid allergy

Stages of Eczematous Stages of Eczematous InflammationInflammation

• Acute, subacute and chronicAcute, subacute and chronic• Do not have to develop in orderDo not have to develop in order• Different clinical appearancesDifferent clinical appearances

Acute InflammationAcute Inflammation

• Tends to be more sudden in onsetTends to be more sudden in onset• May mimic cellulitisMay mimic cellulitis• Boggy, +/-vesicle formation (poison ivy)Boggy, +/-vesicle formation (poison ivy)

– Often weeps and crusts (yellowish serous exudate)

• May be accompanied by Id reaction May be accompanied by Id reaction – eczematous rash with +/-vesicles on a distant

body site

Acute on mild chronic changesAcute on mild chronic changes

Acute with chronic changes including depressed scarsAcute with chronic changes including depressed scars

Subacute InflammationSubacute Inflammation

• More prolonged, insidious in onsetMore prolonged, insidious in onset• Tends to be dryer, red, scalingTends to be dryer, red, scaling• Scale may be significant (suggesting longer Scale may be significant (suggesting longer

duration)duration)• Most commonly seen in winter months with Most commonly seen in winter months with

increasing drynessincreasing dryness

Subacute Subacute

Subacute to chronic with excoriationsSubacute to chronic with excoriations

Chronic InflammationChronic Inflammation

• Tends to be thicker, lichenified (accentuation Tends to be thicker, lichenified (accentuation of the skin lines, thickening of the skin, may of the skin lines, thickening of the skin, may have thick scale)have thick scale)

• Skin may have a cobblestoned textureSkin may have a cobblestoned texture• Results from long standing inflammation and Results from long standing inflammation and

often chronic scratchingoften chronic scratching• Not the same as chronic stasis changesNot the same as chronic stasis changes

Severe chronic dermatitis with hyperkeratosisSevere chronic dermatitis with hyperkeratosis

Chronic dermatitis with fibrosis and hyperkeratosisChronic dermatitis with fibrosis and hyperkeratosis

Chronic SD ChangesChronic SD Changes

• Due to repeated flares and long standing VIDue to repeated flares and long standing VI• Most common over the medial lower leg/ankleMost common over the medial lower leg/ankle• Skin becomes diffusely hyper-pigmented Skin becomes diffusely hyper-pigmented

(hemosiderin deposition), may be thickened or (hemosiderin deposition), may be thickened or atrophied with smooth shiny surfaceatrophied with smooth shiny surface

• Scarring and fibrosis may present with hypo-Scarring and fibrosis may present with hypo-pigmentation and avascuarizationpigmentation and avascuarization– Atrophie blanche, inverted champagne bottle

Moderate stasis changesModerate stasis changes

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

Chronic stasis changes with vascular thrombosisChronic stasis changes with vascular thrombosis

Chronic changes with ulcerChronic changes with ulcer

UlcersUlcers

• Primarily occur on medial lower extremityPrimarily 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

Ulcers - When To BiopsyUlcers - When To Biopsy

• Not responding to therapy (carefully measure)Not responding to therapy (carefully measure)• Very long standingVery long standing• Unusual appearanceUnusual appearance• Unsure of diagnosisUnsure of diagnosis• DDx of Ulcers – arterial, neuropathic, DDx of Ulcers – arterial, neuropathic,

infectious, immunologic, neoplastic, infectious, immunologic, neoplastic, hematologic, infestationshematologic, infestations

Typical Clinical CourseTypical Clinical Course

• Pts have a history of mild swelling of lower Pts have a history of mild swelling of lower legs 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 Swelling gradually worsens over time – Is exacerbated by high salt intake, prolonged

standing it is worse at night and better in the morning

Clinical Course ContinuedClinical Course Continued

• Legs get dry especially in winterLegs get dry especially in winter• Severe flares with burning itch are more Severe flares with burning itch are more

common (acute on chronic inflammation)common (acute on chronic inflammation)• The color of the lower legs slowly changes The color of the lower legs slowly changes

darkening becoming chronically red browndarkening becoming chronically red brown• Tissue becomes fibrosed or bound down Tissue becomes fibrosed or bound down

feeling, areas of scar may appearfeeling, areas of scar may appear• Ulcers begin medially, healing slowly Ulcers begin medially, healing slowly

HistoryHistory

• How severeHow severe– Only in evening, gone in morning, all the time,

drainage, history of ulcer

• SymptomsSymptoms– Burn, itch, fatigue, pain

• Prior treatmentPrior treatment– What are they applying (creams, topical

antibiotics, peroxide etc)

HistoryHistory• Review past medial history Review past medial history

– CHF, DM, neuropathy, DVT, trauma (surgery), varicosities, arthritis, poor mobility, protein loss

• MedicationsMedications– Calcium channel blockers, diuretics- compliance

• How long have they had swellingHow long have they had swelling– If recent, prolonged sitting or immobilization, pain in calf,

unilateral or bilateral

• SocialSocial– Do they sleep in a flat bed or sitting in a chair

Physical ExamPhysical Exam• General examGeneral exam

– Pulmonary exam, cardiac exam as indicated

• Pitting edemaPitting 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?Varicosities?

Physical Exam ContinuedPhysical Exam Continued

• Chronic stasis changesChronic stasis changes– Pigment changes, atrophie blanche, ulcer scars

• Is it hot, cool, tenderIs it hot, cool, tender• Evidence of neuropathy (touch toes and sole Evidence of neuropathy (touch toes and sole

or nylon bristle)or nylon bristle)• Check pulses (may be hard to feel with severe Check pulses (may be hard to feel with severe

edema), capillary refilledema), capillary refill• Check both legsCheck both legs

Treatment of SDTreatment of SD

• Treat underlying diseaseTreat underlying disease– Venous reflux, CHF

• Treat the underlying cause – blood is pooling Treat the underlying cause – blood is pooling in the in the TISSUETISSUE of the lower leg of the lower leg– ***The bulk of fluid is in the tissue but the patient

may be intravascularly euvolemic***

• Treat the inflammationTreat the inflammation– Reduce the inflammation and repair the skin

Treat ‘Tissue’ Fluid OverloadTreat ‘Tissue’ Fluid Overload

• Compression and elevation – most importantCompression and elevation – most important• Compression hose – knee high is usually OKCompression 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

After two days of ACE wrap

Treating ‘Tissue’ Fluid OverloadTreating ‘Tissue’ Fluid Overload

• Compliance – always an issueCompliance – always an issue• Tubey gripsTubey grips

– Elastic stocking that comes in 3 sizes, Rx to fold over in a double layer, pts have to be measured

• OTC HoseOTC Hose– Light, easier to get on, less uncomfortable , come in

colors– Wearing less effective hose is more effective than not

wearing more effective hose

Treating ‘Tissue’ Fluid OverloadTreating ‘Tissue’ Fluid Overload• ElevationElevation

– 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’)

Treating ‘Tissue’ Fluid OverloadTreating ‘Tissue’ Fluid Overload

• ***Diruetics******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

Unna BootUnna Boot

• A zinc oxide impregnated gauze, covered A zinc oxide impregnated gauze, covered with cotton cling and then a double layer of with cotton cling and then a double layer of cobancoban– 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

Unna BootUnna Boot• How to applyHow 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

Modified Unna BootModified Unna Boot

• Apply clobetasol Apply clobetasol ointmentointment, followed by cling , followed by cling and cobanand coban

• Good for short duration (2-4 days)Good for short duration (2-4 days)• Decreases inflammationDecreases inflammation• I bill as for an Unna bootI bill as for an Unna boot

The Last Thing on Unna BootsThe 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 bootCoding for Unna boot– 29508– Medicare allowable: $43.16 (Kingston region)

Decreasing Inflammation Decreasing Inflammation (‘Dermatology Part’)(‘Dermatology Part’)

• Topicals Topicals • Class I or II steroid in an Class I or II steroid in an ointmentointment base base

– Clobetasol (class I) (My ‘go to’)– Fluocinonide (Lidex) (class II)– Ointments are less likely to cause contact allergy

• Apply BID for 10 – 14 daysApply BID for 10 – 14 days• No other topicals - No other topicals - except Vaseline if neededexcept Vaseline if needed

Decreasing InflammationDecreasing Inflammation• Systemic cortisonesSystemic cortisones

– Infrequently used because topicals work well and side effects

– Used for Id reaction (widely distributed eczematous reaction)

• Consider infectionConsider infection– Culture it! – especially for an odiferous or non

healing ulcer– Don’t ‘jump to antibiotics’

Maintenance CareMaintenance Care

• Compression and elevation Compression and elevation – Negotiate a means to maintain minimal edema– Education, education, education– Compliance , compliance, compliance – its always an

issue

• Skin careSkin care– Moisturize with Vaseline only– Limit steroid to 1-2 days per week, BID up to 10 days

for flare

Ulcer TreatmentUlcer Treatment

• Consider culture or biopsy if NOT respondingConsider culture or biopsy if NOT responding– All biopsies carry a risk of worsening the ulcer

• Wound careWound 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

Patient after 6 months at wound care

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

Case ICase I

• 52 YO woman, works as a toll collector, sits 52 YO woman, works as a toll collector, sits on a stool or stands 8 hours a dayon a stool or stands 8 hours a day

• Swelling in legs worsening over last year, Swelling in legs worsening over last year, better in morningbetter in morning

• Legs get red and are now slightly discoloredLegs get red and are now slightly discolored• Not using moisturizer, no other topicalsNot using moisturizer, no other topicals• Itch at timesItch at times

Moderate edema with mild stasis changesModerate edema with mild stasis changes

Case I TreatmentCase I Treatment• Hose (education) Hose (education)

– Mild to moderate especially for prolonged standing or sitting (sell it) (OTC for compliance and esthetics)

• Elevate (education) Elevate (education) – When able, bottom 1/3 of bed… recurring dividend

• Moisturize (education) Moisturize (education) – Cream or vaseline especially in winter

Case IICase II

• 48 YO obese female with history of leg edema 48 YO obese female with history of leg edema following child birth now with chronic swelling, following child birth now with chronic swelling, stands at auto parts counter 8 hrs per daystands at auto parts counter 8 hrs per day

• Worsening, has swelling in morning, painWorsening, has swelling in morning, pain• Has not had an ulcerHas not had an ulcer• Severe redness and itch at timesSevere redness and itch at times• Uses OTC anti-itch cream, polysporinUses OTC anti-itch cream, polysporin

Case II TreatmentCase II Treatment

• Hose (education) Hose (education) – Mod compression all day maybe tubey grips HS

• Elevation (education) Elevation (education) – Over lunch, evening, bed (be realistic)

• Topical (education) Topical (education) – Moisturize daily with Vaseline– Clobetasol Ung for flares BID up to 10-14 days

Case IIICase III

• 72 YO male, DMII and arthritis72 YO male, DMII and arthritis• Many year history of swelling, worse now, Many year history of swelling, worse now,

pain, oozing at times, R > L legs pain, oozing at times, R > L legs • Ulcer 3 years ago, healed at wound centerUlcer 3 years ago, healed at wound center• Wears old hose sometimes – don’t helpWears old hose sometimes – don’t help• Using peroxide to dry up the legsUsing peroxide to dry up the legs• Sleeps in a bedSleeps in a bed

Note cut socksNote cut socks

Case III TreatmentCase III Treatment• New hose (education)New hose (education)

– Moderate (rubber gloves, cuff), OTC, tubey grips

• Elevation (education) Elevation (education) – Recliner, bed (dividend), whenever sitting

• TopicalsTopicals– Bathe regularly, clobetasol ointment BID for 2

weeks then vaseline daily

• FU – 2 weeks (education, compliance)FU – 2 weeks (education, compliance)

Case IVCase IV

• 72 YO morbidly obese female with long standing 72 YO morbidly obese female with long standing swelling and scaling, recently worse, history of swelling and scaling, recently worse, history of CHF takes Lasix 20 mg BID (+/-), arthritisCHF takes Lasix 20 mg BID (+/-), arthritis

• Leg is oozing fluid, non painful ulcerLeg is oozing fluid, non painful ulcer• No hoseNo hose• Lives alone and sleeps sitting in a chair Lives alone and sleeps sitting in a chair • No topicalsNo topicals

Case IV TreatmentCase IV Treatment• Hose (education) Hose (education)

– Clobetasol ung and Ace wrap today, to leave on over night and Una Boot in the AM

• Elevation (education)Elevation (education)– Recliner, bottom 1/3 of bed (be persistant)

• Topicals to be addressed as per case IIITopicals to be addressed as per case III• MedicalMedical

– ? Change Lasix to 40mg QD, when?, ? Echo etc

• FU 4 – 7 days, ? Visting or office nurse visitFU 4 – 7 days, ? Visting or office nurse visit

Thank you !Thank you !

Questions?Questions?