Description

• Chronic, eczematous, erythremic, scaling, and noninflammatory edema of the lower extremities accompanied by cycle of scratching, excoriations, weeping, crusting, and inflammation in patients with chronic venous insufficiency, due to impaired circulation and other factors (nutritional edema)
• Clinical skin manifestation of chronic venous insufficiency usually appears late in the disease.
• May present as a solitary lesion
• System(s) affected: Skin/Exocrine
• Synonym(s): Gravitational eczema; Varicose eczema; Venous dermatitis

Epidemiology

• In the US: Common in patients age >50 years (6–7%)
• Predominant age: Adult, geriatric
• Predominant sex: Female > Male

Geriatric Considerations
Common in this age group:

• Estimated to affect 15–20 million patients age >50 years in the US

Risk Factors

• Atopy
• Superimposition of itch–scratch cycle
• Trauma
• Previous deep vein thrombosis (DVT)
• Previous pregnancy
• Prolonged medical illness
• Obesity
• Secondary infection
• Low-protein diet
• Old age
• Genetic propensity
• Chronic edema
• Tight garments that constrict the thigh
• Vein stripping
• Vein harvesting for coronary artery bypass graft surgery
• Previous cellulitis

Genetics
Familial link probable

General Prevention

• Use compression stockings to avoid recurrence of edema and to mobilize the interstitial lymphatic fluid from the region of stasis dermatitis, and also following DVT.
• Topical lubricants twice a day to prevent fissuring and itching

Etiology

• Incompetence of perforating veins causing blood to backflow to the superficial venous system leading to venous hypertension (HTN) and cutaneous inflammation
• Deposition of fibrin around capillaries
• Microvascular abnormalities
• Ischemia
• Continuous presence of edema in ankles, usually present because of venous valve incompetency (varicose veins)
• Weakness of venous walls in lower extremities
• Trauma to edematous, eczematized skin
• Itch may be caused by inflammatory mediators (from mast cells, monocytes, macrophages, or neutrophils) liberated in the microcirculation and endothelium.
• Abnormal leukocyte–endothelium interaction is proposed to be a major factor.
• A cascade of biochemical events leads to ulceration.

Commonly Associated Conditions

• Varicose veins
• Venous insufficiency
• Other eczematous disease
• Hyperhomocysteinemia
• Venous hypertension (1)