Skin Care Today

SKIN CARE TODAY

2017,Vol 3, No 1

FOCUS ON VENOUS ECZEMA

›

Population ageing (van

Langevelde et al, 2010; Chi and

Raffetto, 2015)

›

Falling activity levels (Department

of Health [DH], 2011)

›

Increasing numbers of adults who

are overweight and obese (Lumley

et al, 2015; Public Health England

[PHE], 2016).

PRINCIPLES OF DIAGNOSIS

AND TREATMENT

It is important to diagnose venous

eczema accurately, and to identify

and treat any associated problems,

such as infection, and work with

the patient to maintain health and

wellbeing and improve quality of

life (

Figure 2

Diagnosis of venous eczema

This is made on the basis of

clinical features (Bergan et al, 2006;

Middleton, 2007;

Table 2

). Venous

eczema can be misdiagnosed as

‘bilateral cellulitis’(Nazarko, 2013),

with research indicating that around

28–33% of people diagnosed as

having cellulitis are misdiagnosed

(David et al, 2011; Levell et al,

2011). Around half of those

cases of misdiagnosed cellulitis

are venous eczema, a smaller

percentage are lymphoedema and

lipodermatosclerosis (Quartey-

Papafio,1999; Cox, 2002; Levell et al,

2011).

Table 2

outlines the clinical

features of lipodermatosclerosis,

venous eczema and cellulitis.

Treatment and management

Pigmentary changes (commonly

referred to as staining) are common

in venous eczema, and it is

important to differentiate between

inflammatory changes that may

require treatment and pigmentary

changes that do not (

Figure 3

Pigmentation changes occur

because high venous pressure

causes blood to leak from the

capillaries into the tissues.

The haemoglobin in the blood

is oxidised and haemosiderin

deposition occurs. This leads to the

skin on the lower legs becoming

red or brown. Staining is an

important indicator of venous

disease but can be confused with

infection, as clinicians misinterpret

the colour change as indicative of

infection despite the lack of clinical

indications (Graham et al, 2003).

Clinically, staining looks brown or

reddish brown while inflamed skin

is redder. Skin that is stained feels

and looks smooth. Inflamed skin

feels and looks a little lumpy and

bumpy.

Figures 3

and

illustrate

the differences.

Treating red itchy inflamed skin

The role of topical steroids in

managing flare ups

Emollients are essential in the

treatment of venous eczema and

should be used at least once a day

and more often if needed (Barron et

al, 2007; Nazarko, 2010). Steroids are

used in conjunction with emollients

to treat acute and subacute flare ups

of eczema. The order in which these

should be applied is not known,

however they should be applied 30

minutes apart (Ladva, 2012).

Steroids are an essential aspect of

treatment of severe venous eczema,

with topical steroids being classified

according to potency (

Figure 5

Steroid creams are usually applied

daily, and application of potent

steroids, such as betamethasone

valerate 0.1%, will flatten raised

red patches of skin and treat

inflammation (Oakley, 2014). They

should be applied for at least two

weeks, as discontinuing early can

›

Practice point

Some features of venous eczema

require treatment, while others

do not.

Table

CEAP classification — chronic

venous disorders (Eklof et al, 2004)

›

No visible or palpable signs of

venous disease

›

Telangiectasia (spider veins) or

reticular veins

›

Varicose veins, distinguished from

reticular veins by a diameter of 3mm

or more

›

Oedema

›

Changes in skin and subcutaneous

tissue secondary to chronic venous

disease, divided into two sub-classes

to better define the differing severity

of venous disease

C4a

›

Pigmentation or eczema

C4b

›

Lipodermatosclerosis or

atrophie blanche

›

Healed venous ulcer

›

Active venous ulcer

›

The facts... pathophysiology of venous disease

Arteries bring oxygenated blood from the heart and veins return de-

oxygenated blood back to the heart. The legs contain deep and superficial

veins and these contain valves that prevent backflow of blood (

Figure 1

The deep veins in the legs can be damaged by conditions that raise

venous pressure. These include pregnancy, obesity, abdominal tumours or

direct injury such as a thrombosis in one of the deep veins in the legs (deep

vein thrombosis [DVT]). High pressure stretches and pushes the valve apart

and they becomes damaged and no longer work effectively. This leads to a

further increase in pressure and failure of the next valve along, which results

in established high pressure in the veins — chronic venous hypertension

causing backflow of blood into the thin walled superficial veins, which

subsequently become stretched and dilated. This causes further backflow of

blood and increased pressure in the superficial veins and capillary distension,

which leads to blood and plasma leaking into the tissues. It is thought that

this results in an inflammatory reaction resulting in venous eczema and skin

damage (National Institute for Health and Care Excellence [NICE], 2012;

NHS Choices, 2015; National Eczema Society, 2015; British Association of

Dermatologists [BAD], 2016).