DermatologyTier 1Disease (DEADMAN)

Dermatitis - stasis

Description

Eczematous dermatitis of the lower legs secondary to chronic venous insufficiency - the cutaneous companion condition to venous ulceration, not a separate disease process
Gaiter distribution (lower 1/3 leg, medial > lateral) - erythema, scaling, itching, +/- weeping
Part of the same spectrum as lipodermatosclerosis and venous ulcers - same venous hypertension mechanism, different clinical expression

Common in the elderly; risk factors mirror chronic venous insufficiency - obesity, prior DVT, varicose veins, immobility, multiparity, prolonged standing occupations

Venous hypertension (valvular incompetence, calf pump failure, post-thrombotic syndrome) -> capillary leakage of fibrinogen/red cells into the dermis -> haemosiderin deposition and chronic inflammation -> eczematous skin change
Chronic scratching/irritation -> secondary contact allergic sensitisation is common (to topical treatments applied, e.g. lanolin, fragrance, preservatives) - stasis dermatitis is one of the highest-risk settings for iatrogenic contact allergy
Progresses on the same spectrum toward lipodermatosclerosis (woody fibrotic induration) and ulceration if venous hypertension uncorrected

Clinical

Erythematous, scaly, itchy plaques in the gaiter region, often bilateral but asymmetric; haemosiderin (brown) pigmentation is a supporting clue
Associated venous signs: varicose veins, oedema, lipodermatosclerosis, atrophie blanche

When to investigate further

Patch testing if dermatitis worsens despite standard treatment or is unusually itchy/vesicular - screen for contact allergy to a topical agent being used (very common confounder)
ABPI before considering compression, as for venous ulcers
Consider cellulitis as a differential/complication if acute unilateral spreading erythema with systemic symptoms - stasis dermatitis is often bilateral and chronic, cellulitis usually unilateral and acute

A. Treat the venous hypertension, not just the skin

Compression therapy (once ABPI excludes significant arterial disease) - addresses the underlying driver
Leg elevation, weight management, regular ambulation

B. Treat the dermatitis

Topical corticosteroid (moderate potency) for active inflammation/itch - short courses, as chronic potent steroid use on already-fragile venous skin risks atrophy
Emollients regularly to maintain barrier
Avoid lanolin/fragranced products given high rate of secondary contact sensitisation in this group

C. Secondary complications

Treat overt secondary infection/cellulitis if present (differentiate from an acute flare of dermatitis)
Refer for patch testing if refractory despite adherence

Chronic venous insufficiency, varicose veins, lipodermatosclerosis, venous ulceration - same disease spectrum
Secondary contact allergic dermatitis to topical treatments (lanolin, fragrance, topical antibiotics)
Obesity, immobility, prior DVT

Chronic, relapsing without correction of venous hypertension
Progression along the venous disease spectrum - untreated stasis dermatitis with ongoing venous hypertension predisposes to lipodermatosclerosis and eventual ulceration
Recurrent excoriation/scratching - risk of secondary bacterial infection and further contact sensitisation
Compression therapy and venous intervention (where appropriate) improve both the dermatitis and prevent progression to ulceration

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