Varicose Eczema

Posted in Disease Information

Introduction

Varicose eczema is a type of eczema that affects the legs. Like all types of eczema, the skin becomes red, flaky, scaly and itchy.

Varicose eczema is also known as venous eczema or gravitational eczema.

Varicose eczema usually develops in the skin over and around varicose veins. It is usually a minor annoyance and leads to no major problems.

Eczema

Eczema is the name for a group of skin conditions that cause dry, irritated skin. Other types of eczema include:

• atopic eczema (also called atopic dermatitis)
• contact dermatitis – a type of eczema that occurs when the body comes into contact with a particular substance
• discoid eczema – causes circular or oval patches of eczema

What causes varicose eczema?

Varicose eczema is usually caused by varicose veins. These are swollen and enlarged veins that are blue or dark purple. They may also be lumpy, bulging or twisted in appearance.

Varicose veins develop when the small valves inside the veins stop working properly and allow blood to flow backwards, leading to swollen and enlarged varicose veins.

The pressure inside these veins increases which can damage the skin, leading to varicose eczema as well as more severe skin damage.

Treating varicose eczema

Treatment for varicose eczema involves treating both the dry skin and the underlying blood flow problem. Emollients, which are moisturisers applied to the skin to reduce the loss of water, are often recommended. These also help to soothe the skin. Corticosteroid ointments are also used to help manage severe symptoms.

Elastic medical compression stockings, which are specially designed stockings that steadily squeeze your legs, can help to improve your circulation. You will need to wear them every day.

These treatments are usually enough to control varicose eczema. However, if they are not effective or if you have lipodermatosclerosis, a more severe form of venous skin damage, you may be referred to a vascular specialist (a doctor who specialises in veins). They can investigate and treat the underlying venous problem. Treatment of varicose veins will often cure varicose eczema, lipodermatosclerosis and venous ulcers.

Who is affected

Skin problems due to venous disease (problems with your veins) become more common with age and tend to affect women more than men. Some estimates suggest that venous disease causes skin changes in 3% of adults. This rises to 20% of people above 70 years old.

You may be more likely to develop venous skin problems if you:

• Have varicose veins
• Are overweight, as this puts extra pressure on your veins

Symptoms of varicose eczema

The first sign of varicose eczema is mild itchiness of your skin over and around a patch of varicose veins.

The skin then becomes speckled, scaly, inflamed and itchy. In some cases the skin may turn brown and feel very hard to the touch.

Severe skin disease may be caused by vein problems in your leg. This usually occurs near your ankle and may extend onto your foot and as far as the mid-calf.

Lipodermatosclerosis

In some people, the area becomes red and inflamed and can be painful. This problem is called lipodermatosclerosis.

The symptoms of lipodermatosclerosis include:

• Hard, tight skin
• Red or brown coloured skin
• The layer of fat and soft tissues underneath the skin (subcutaneous tissue) may become hard, causing the leg to look like an upside-down champagne bottle

Leg ulcers

Vein problems may also cause a leg ulcer. This is a damaged area where the skin has broken down into an ulcer (a chronic non-healing wound).

Causes of varicose eczema

Varicose eczema is usually caused by varicose veins, which develop when the small valves inside the veins stop working properly.

Varicose veins are swollen and enlarged veins that are usually blue or dark purple. They may also be lumpy, bulging or twisted in appearance.

Varicose veins

Inside your veins there are one-way valves that open to let the blood through, then close to prevent it flowing backwards.

Sometimes, the walls of the veins can become stretched and lose their elasticity, causing the valves to become weakened. If the valves do not function properly, the blood may leak backwards past the valves. If this happens, the blood collects in your veins, which become swollen and enlarged (varicose veins).

This causes the pressure inside these veins to increase, which can damage the skin and lead to varicose eczema as well as more severe skin damage such as lipodermatosclerosis or a venous leg ulcer.

It is not fully understood why the walls of the veins stretch and the valves weaken. Some people develop the condition for no obvious or apparent reason, although there are some risk factors, such as age or being pregnant.

Deep vein thrombosis

Deep vein thrombosis (DVT) is a blood clot in one of the deep veins in the body. A blood clot in one of the veins in your leg may block the flow of blood and damage the valves. This can increase pressure in the vein and lead to severe skin damage, such as lipodermatosclerosis.

DVT sometimes occurs for no apparent reason, but may be more likely to occur if you are immobile (unable to move) for a long period of time – for example, if you are recovering from an operation in hospital. There are a number of other possible causes and risk factors, such as heart and lung disease.

Increased risk

A number of things can increase your likelihood of developing varicose eczema and lipodermatosclerosis, including:

• Your age – as you get older, your veins start to lose their elasticity and the valves inside them stop working as well
• Your gender – varicose eczema is more common among women
• Your weight – being severely overweight puts extra pressure on your veins, which means that they have to work harder; it also increases the pressure on the valves, making them more prone to leaking

Diagnosing varicose eczema

See Dr. B C Shah if you are having symptoms of varicose eczema. They can usually make a diagnosis by simply looking at the affected areas.

Dr. B C Shah  will ask you some questions to find out whether you have increased blood pressure in your veins. This causes varicose eczema, so it will support your diagnosis and help to rule out other possible causes of a leg rash such as contact dermatitis.

Signs of increased venous blood pressure include having a history of:

• Varicose veins (swollen and enlarged veins)
• Deep vein thrombosis (DVT) – a blood clot in one of the deep veins in your body
• Leg ulcers – damaged skin below the knee on your leg or foot that takes longer than six weeks to heal

If Dr. B C Shah is in doubt, then he will arrange for further tests.

Referral

Dr. B C Shah may refer you to a vascular specialist (a doctor who specialises in veins) or a dermatologist (a specialist in treating skin conditions) if:

• You have varicose veins and changes to your skin, such as varicose eczema, lipodermatosclerosis or a history of leg ulcers (chronic non-healing wounds)
• You have very poor blood flow in the arteries (blood vessels) in your legs
• Your eczema does not get better despite treatment
• It is possible that you may have contact dermatitis – a type of eczema that occurs when the body comes into contact with a particular substance

Treating varicose eczema

Treatment for varicose eczema aims to improve the condition of your skin and help your circulation (blood flow). If you have any underlying vein problems they will also need to be treated.

Treatment options may include:

• Emollients (moisturisers)
• Topical corticosteroids
• Graduated elastic medical compression stockings

There are also some self-help techniques that you can try. These treatment options are described in more detail below.

If you have varicose veins, graduated elastic medical compression stockings will often help to treat these as well. However, in some cases, surgery may be necessary.

Lipodermatosclerosis (hardened, tight skin) is treated the same way as varicose eczema. If you have a venous leg ulcer, you can also read information about treating venous leg ulcers.

Self-help

There are some steps you can take to care for your varicose eczema:

• Avoid injuring your skin – for example, by knocking into a chair because this could lead to an ulcer (open sore) developing
• Raise your legs when you are resting – for example, by propping up your feet on some pillows, to help reduce swelling
• Keep physically active, because this will improve your circulation and enable you to maintain a healthy weight

Exercise

Fluid accumulates in the lower legs if you stand or sit for too long, so it is important to keep moving. Walking will get your muscles working and help to push the blood through the veins to your heart. It is recommendable to do the following:

• Flexing your feet regularly
• Rising up onto your toes or bending down at the knees

Emollients

Emollients are substances that help to soften and smooth your skin to keep it supple and moist. They are one of the most important forms of treatment for all types of eczema.

As varicose eczema can cause your skin to become dry and cracked, it is important to keep it moisturised to prevent further irritation. Emollients prevent water being lost from your outer layer of skin (epidermis), as well as adding water to the skin. They act as a protective barrier to keep the moisture in and the irritants out.

Choice of emollient

A number of different emollients are available. Some can be bought over the counter without a prescription, but if you have varicose eczema ask Dr. B C Shah to recommend a suitable product.

You may need to try several different emollients to find one that works for you. You may also be prescribed a mix of emollients. For example:

• An ointment for very dry skin
• A cream or lotion for less dry skin
• An emollient to use instead of soap
• An emollient to add to bath water or use in the shower

The difference between lotions, creams and ointments is the amount of oil that they contain. Ointments contain the most oil so they can be quite greasy, but are the most effective at keeping moisture in the skin. Lotions contain the least amount oil so are not greasy, but can be less effective. Creams are somewhere in between.

If you have been using a particular emollient for some time, it may eventually become less effective or may start to irritate your skin. If this is the case, Dr. B C Shah will be able to prescribe another product.

How to use emollients

You should use your emollient all the time, even if you are not having symptoms.

To apply the emollient:

• Use a large amount
• Smooth the emollient into the skin in the same direction that the hair grows
• Do not rub the emollient in
• For very dry skin, apply emollient every two to three hours
• After a bath or shower, gently dry the skin, then immediately apply the emollient while the skin is still moist
• Do not share emollients with other people

Creams and lotions tend to be more suitable for red, inflamed (swollen) areas of skin. Ointments are more suitable for areas of dry skin that are not inflamed.

It is very important to keep using your emollients during a flare-up of varicose eczema because this is when the skin needs the most moisture. During a flare-up, apply emollients frequently and in generous amounts.

Side effects

The most common side effect of using emollients is a rash. If you have varicose eczema, your skin is sensitive and can sometimes react to certain ingredients within an emollient. If this happens, speak to Dr. B C Shah who can prescribe an alternative product.

Be aware some emollients contain paraffin and can be a fire hazard. As some emollient products are highly flammable, do not use them near a naked flame.

Emollients added to bath water can make your bath very slippery, so take care getting in and out of the bath.

Topical corticosteroids

If your skin is red and inflamed from a flare-up of varicose eczema, Dr. B C Shah may prescribe a topical corticosteroid (one that is applied directly to your skin). Corticosteroids work by quickly reducing inflammation.

Corticosteroids are any type of medication that contain steroids, a type of hormone.

Choice of topical corticosteroid

Different strength topical corticosteroids can be prescribed depending on the severity of your varicose eczema. If you have flare-ups of lipodermatosclerosis, you may need a very strong topical corticosteroid. Therefore you may be prescribed a cream or an ointment.

If your varicose eczema is moderate to severe, you may need to apply topical corticosteroids between flare-ups and during them.

If you need to use corticosteroids frequently, visit Dr. B C Shah  regularly so he can check that the treatment is working.

How to use topical corticosteroids

When using corticosteroids, apply the treatment sparingly to the affected areas. Always follow directions on the patient information leaflet that comes with the corticosteroid, as it provides details about how much to apply.

During a flare-up of varicose eczema, do not apply the corticosteroid more than twice a day. Most people only have to apply it once a day. When applying the topical corticosteroid, you should:

• Apply your emollient first and wait several minutes before applying the topical corticosteroid (until the emollient has soaked into your skin)
• Apply a small amount of the topical corticosteroid to the affected area
• Use the topical corticosteroid for 7 to 14 days
• Continue to apply the treatment for 48 hours after the flare-up has cleared up

If you are using corticosteroids on a long-term basis, you may be able to apply them less frequently. Dr. B C Shah will advise you about how often you should be applying them.

Also speak to Dr. B C Shah if you have been using a topical corticosteroid and your symptoms have not improved.

How much topical corticosteroid to use

• Topical corticosteroids are measured in a standard unit called the fingertip unit (FTU).
• One FTU is the amount of topical steroid squeezed along an adult’s fingertip.
• One FTU is enough to treat an area of skin twice the size of an adult’s hand.

Side effects

Topical corticosteroids may cause a mild burning or stinging sensation as you apply them. In some areas, they may also cause:

• Thinning of the skin, particularly in the crease of your knee joint
• Telangiectasia (visible blood vessels) – particularly on the cheeks
• Acne (spots)
• Increased hair growth

Generally, using a stronger topical corticosteroid or using a large amount of topical corticosteroid will increase your risk of getting side effects. For this reason, you should use the weakest and smallest amount possible to control your symptoms.

Graduated elastic medical compression stockings

Medical compression stockings are specially designed to steadily squeeze your legs to help improve your circulation. They are often tightest at the ankle and get gradually looser as they go further up your leg. This encourages your blood to flow upwards towards your heart.

Medical compression stockings are used to treat varicose eczema and lipodermatosclerosis. They improve the condition of the skin by reducing the high blood pressure in the veins in the leg.

Compression stockings are available in a variety of different sizes and pressures. Most people with varicose eczema will be prescribed a class 1 (light compression) or class 2 (medium compression) stocking. They are also available in:

• Different colours
• Different lengths – some come up to your knee and some also cover your thigh; you should only need knee-high stockings for varicose eczema
• Different foot styles – some cover your whole foot and some stop before your toes

Compression tights are also available.  They can be bought from pharmacies.

Wearing compression stockings

You will usually need to put your compression stockings on as soon as you get up in the morning and take them off when you go to bed. Wearing compression stockings can be uncomfortable, particularly during hot weather, but it is important to wear them correctly to get the most benefit from them.

Pull them all the way up so that the correct level of compression is applied to each part of your leg. Do not let the stocking roll down or it may dig into your skin in a tight band around your leg. Speak to Dr. B C Shah if the stockings are uncomfortable or if they do not seem to fit. It may be possible to get custom-made stockings that will fit you exactly.

If custom-made compression stockings are recommended, your legs will need to be measured in several places to ensure that your stockings will be the correct size. If your legs are often swollen, they should be measured in the morning when any swelling is likely to be minimal.

Take care when taking your compression stockings on and off because this can damage fragile skin. If you have a leg ulcer, it ideally needs to heal before you start wearing compression stockings.

Caring for compression stockings

Compression stockings usually have to be replaced every three to six months. Speak to Dr. B C Shah if your stockings become damaged, as they may no longer be effective.

You should also be prescribed two stockings (or two sets of stockings if you are wearing one on each leg) so that one stocking can be worn while the other is being washed and dried. Compression stockings should be hand-washed in warm water and dried away from direct heat.

Treating varicose veins

The combination of skin care and compression stockings will help many people with varicose eczema. However, in some cases the eczema persists. In people with severe skin damage due to venous disease treating the underlying venous disease will cure the problem in the long-term.

The most common venous disease that causes skin damage is varicose veins. Dr. B C Shah should  arrange for colour duplex ultrasound imaging of the leg to find the faulty blood vessels. Treatment of the varicose veins can then be planned.

Several modern methods are available that will cure varicose veins and resolve associated varicose eczema, lipodermatosclerosis and venous ulcers. These are usually performed in the day surgery department of a hospital.