Venous eczema and lipodermatosclerosis should be considered in patients with painful dermatitis or pruritic erythematous eruptions on their lower extremities, especially if there are other signs of venous insufficiency, according to Dr. Laurel M. Morton and Dr. Tania J. Phillips.
"Venous eczema and lipodermatosclerosis are relatively common conditions caused by chronic venous insufficiency, yet at times they can be a challenge to diagnose and treat," said Dr. Morton in an interview.
Writing in the September issue of Seminars in Cutaneous Medicine and Surgery, Dr. Morton and Dr. Phillips of the department of dermatology, Boston University, reviewed the challenges associated with the diagnosis and treatment of these conditions (Semin. Cutan. Med. Surg. 2013;32:169-76).
Venous eczema presents as erythematous, scaly, pruritic skin on the lower legs and ankles, often in association with other signs of venous disease such as varicose veins, edema, hemosiderin pigmentation, atrophie blanche, and lipodermatosclerosis.
Lipodermatosclerosis is a progressive fibrotic process affecting the dermis and subcutaneous fat of the lower leg, resulting in hyperpigmentation and induration.
There are few data on the prevalence of venous eczema and lipodermatosclerosis, or even for chronic venous disease in general, the researchers noted. However, they suggested that as many as 17% of men and 40% of women suffer from chronic venous insufficiency, and of the 23% of Americans with varicose veins, 2 million will develop skin changes.
"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization."
Venous eczema can be confused with other papulosquamous conditions such as nummular eczema and psoriasis, as well as xerosis, eczema craquele, and cellulitis.
"Perhaps the most challenging condition to rule out is allergic contact dermatitis, since this may be seen in conjunction with venous eczema, which is characterized by a decreased skin barrier that may increase the rate of sensitization," the researchers reported.
Consider patch testing in cases where allergy is suspected and, if irritant contact dermatitis is a possibility, patients should be asked about topical applications, they added.
Acute lipodermatosclerosis presents as painful, erythematous, purple indurated plaques – well demarcated from normal skin – confined to the lower extremity, possibly with white scale, while chronic lipodermatosclerosis is generally associated with a classic "inverted champagne bottle" appearance of the distal third of the lower leg.
Acute lipodermatosclerosis is also often misdiagnosed as cellulitis, although a key distinguishing factor is lack of improvement with antibiotics. Acute lipodermatosclerosis also can be confused with conditions such as erythema nodosum, thrombophlebitis, and fibrosing conditions such as inflammatory morphea.
As venous eczema and lipodermatosclerosis are caused by venous insufficiency, the authors argue that compression should be the first line of treatment.
"The most important treatment for both conditions is graduated compression, but oral, topical, and surgical interventions should be considered as adjunctive approaches," Dr. Morton said.
Venous eczema also can be managed topically with emollients and immunomodulators – including corticosteroids and calcineurin inhibitors – although scant data support this approach.
However, the researchers highlighted one study in which patients treated with a combination of oral doxycycline and topical tacrolimus showed statistically significant improvement in pain, edema, erythema, pigmentation, pruritus, and exudate (Indian J. Pharmacol. 2012;44:111-13).
Patients with lipodermatosclerosis may not tolerate compression due to extreme skin tenderness; however, there is reasonable evidence in favor of stanozolol, an anabolic steroid with fibrinolytic properties, the researchers noted. Other agents that may help these patients include danazol, oxandrolone, pentoxifylline, and intralesional triamcinolone.
There is little evidence to support the use of ultrasound, the researchers said. However, it is safe and may offer an alternative to other therapeutic options in recalcitrant disease, they added.
The researchers had no financial conflicts to disclose.