Gravitational eczema

Gravitational dermatitis (or eczema) is an itchy rash occurring on the lower legs. It arises when there is venous disease so it also called ‘venous eczema’ and sometimes ‘stasis eczema’.

Normally during walking the leg muscles pump blood upwards and valves in the veins prevent pooling. A clot in the deep leg veins (deep venous thrombosis or DVT) or varicose veins may damage the valves. As a result back pressure develops and fluid collects in the tissues.

The affected leg is usually swollen, particularly after prolonged standing and during hot weather. Swelling is due to inflammation and lymphoedema. Dermatitis can arise as discrete patches or affect the leg circumferentially. The affected skin is red and scaly, and may ooze, crust and crack. It is frequently itchy.

Venous disease

Gravitational eczema

Lipodermatosclerosis

Gravitational ulcer

Complications

• Impetiginisation: secondary infection with Staphylococcus aureus resulting in yellowish crusts
• Cellulitis: infection with Streptococcus pyogenes: there may be redness, swelling, pain, fever, a red streak up the leg and swollen nodes in the groin.
• Autosensitisation reaction: the dermatitis spreads to affect other areas on the body.
• Lichenification: skin thickening due to rubbing
• Hyperpigmentation: the skin darkens in colour.
• Lipodermatosclerosis: the deeper tissues become ´woody´ in texture. Lipodermatosclerosis is a form of panniculitis.
• Atrophie blanche: white scarred areas surrounded by tiny red spots (enlarged capillaries).
• Ulceration, frequently over the inner aspect of the ankle provoked by a minor injury.
• Contact allergy to one or more components of the ointments or creams used, specifically identified by patch testing.

To reduce swelling in the leg

• Don't stand for long periods.
• Take regular walks.
• Elevate your feet when sitting: if your legs are swollen they need to be above your hips to drain effectively.
• Elevate the foot of your bed overnight.
• Once the dermatitis is under control, wear special graduated compression stockings long term. These can be obtained from a surgical supplies company.
• Horse chestnut extract appears to be of benefit for at least some patients with venous disease.

To treat the dermatitis

• Dry up oozing patches with Condy's solution (potassium permanganate) or dilute vinegar on gauze as compresses.
• Oral antibiotics such as flucloxacillin may be prescribed for secondary infection.
• Apply a prescribed topical steroid: start with a potent steroid cream applied accurately daily to the patches until they have flattened out. After a few days, change to a milder steroid cream (eg. hydrocortisone) until the itchy patches have resolved (maintenance treatment). Check with your doctor if you are using steroid creams for more than a few weeks. Overuse can thin the skin, but short courses of stronger preparations can be used from time to time if necessary to control the dermatitis. Coal tar ointment may also help.
• Use a moisturising cream frequently to keep the skin on the legs smooth and soft.
• Try not to scratch: it keeps the dermatitis going.
• Protect your skin from injury: this can result in infection or ulceration.

Treatment for varicose veins

• Seek the opinion of a vascular surgeon regarding an operation to remove varicose veins.
• Varicose veins may develop again after apparently successful operation because venous disease is progressive.
• Sometimes, the veins of the lower leg can be treated by injection (sclerotherapy). Sclerotherapy is particularly successful for smaller thread veins.