Venous stasis dermatitis (VSD) is defined as a cutaneous disease that primarily affects the elderly, manifesting in the lower extremities. It is a chronic inflammatory skin disorder detected predominantly in people with chronic venous insufficiency, a condition characterised by impaired blood flow from the lower limbs to the heart.1 This typically arises from a dysfunction in the valves of the heart, potentially resulting in blood reflux (where blood cannot be pumped back to the heart and flows backwards, pooling in the lower limbs) and subsequent venous hypertension.1
The clinical manifestation of VSD includes symptoms like leg pain and swelling, which are primarily associated with incompetent venous valves. Furthermore, it involves skin tissue alterations induced by inflammatory processes, with venous ulcers emerging in more advanced stages of the disease. Diagnosis of VSD can be particularly challenging due to its clinical similarities with other skin disorders and limited awareness among healthcare practitioners.1
Recognition of early symptoms and prompt diagnosis are imperative for preventing the progression of the disease towards more painful advanced stages, such as ulcers, which may also elevate the risk of developing squamous cell carcinoma.2
The objective of this article is to provide a comprehensive understanding of VSD, explore the various risk factors associated with the disease, and delve into different management strategies.
Anatomy and physiology of the venous system
To better grasp the physiological aspects of VSD, a basic understanding of the vascular system and its functions is necessary. The peripheral vascular system encompasses all blood vessels outside of the heart and includes the following branches of the aorta:
- Arteries: Arteries are responsible for supplying blood and nutrients to the organs. They are always under consistently high pressure and adjust their diameter to regulate blood flow.3
- Arterioles: Arterioles are smaller branches that further divide from arteries. They can also modify their diameter to control blood flow and the exchange of nutrients and oxygen within tissues.3
- Capillaries: Oxygen-rich blood is transported from the arterioles to the capillaries.3
- Venules: Blood enters venules after the capillaries.3
- Veins: Venules direct blood into larger veins. They contain a high blood volume in the circulatory system. Within veins, one-directional valves facilitate blood flow towards the heart.3
Causes and risk factors
As previously mentioned, a defect in the one-way valves located within the veins is responsible for the inefficient return of blood from the lower legs to the heart. This defect may arise from poor valve function, valve destruction, or venous obstruction, resulting in the backflow of venous blood into the limbs, a condition known as venous hypertension.4 Likewise, insufficient contraction of the calf muscles, responsible for facilitating blood return to the heart, is also associated with venous hypertension.4 This elevated venous pressure, the sectional build-up of inflammatory cells, and their leakage from the circulation into the surrounding tissue give rise to inflammatory reactions that conclude the cutaneous presentation of VSD.4
Secondary causes and contributing factors to the development of the disease include:
- Female sex
The female sex hormones and their receptors have been specifically linked to the formation of varicose veins, an initial indicator of chronic venous insufficiency. This connection underscores epidemiologic studies that indicate a higher propensity for women to develop this particular vascular dysfunction.1,5
- Obesity and pregnancy
The correlation between VSD and obesity or pregnancy arises from the increased stress placed on the lower limbs of patients as a result.1
The geriatric population is notably predisposed to a higher incidence of venous pathologies, including VSD.1
- Prolonged sedentary lifestyle and prolonged standing
In both scenarios, patients might experience muscle, joint or skeletal deterioration, including calf muscle deficits, which can impact vascular function by promoting venous hypertension and VSD.4
- History of deep vein thrombosis
In general, a prior occurrence of blood clot formation in the limbs, as in the case of deep vein thrombosis, has been linked to valvular dysfunction, chronic venous insufficiency and consequently VSD.4,6
Symptoms of VSD
A specific classification method entitled CEAP - clinical manifestations (C), aetiology (E), anatomy (A) and pathophysiology (P )- has been established to categorise chronic vascular diseases.6 VSD has been classified as a C4 degree of vascular dysregulation, signifying alterations in the skin and subcutaneous tissue.1 Specifically, the skin exhibits erythematous and eczematous plaques on both lower legs, particularly on the inner side of the ankle.4 Additional symptoms include oedema (swelling), aching, pruritus (itching), discoloured skin and scaling, among others.1
Itching poses a significant challenge and is the most troublesome symptom of VSD, capable of triggering persistent scratching that may exacerbate wounds and heighten the risk of skin infections. According to a survey conducted in elderly people, patients experiencing itching reported a lower quality of life and higher levels of leg pain compared to those without.1
Advanced stages of the disease, characterised by progressive inflammatory responses and skin damage in the affected area, may eventually culminate in the development of venous ulcers and more severe complications.1
Complications and diagnostic tools
Misdiagnosis is relatively common due to the similarities between VSD and other dermatological conditions, such as allergic contact dermatitis, cellulitis and pigmented purpuric dermatoses. Therefore, in cases where a rash is present in the lower limbs of patients, consulting a dermatologist is crucial for accurate disease identification and exploration of treatment options to improve the quality of life of the elderly population.7
Clinical diagnosis relies on histological epidermal findings and medical history. Specific inflammatory cells and processes may be identified in the affected area, confirming the presence of VSD. Biopsies may be considered. However, they are mostly avoided due to difficulty in wound healing and the potential to provoke ulcers.1 A duplex ultrasound to validate the presence of venous reflux might be convenient in cases where other VSD diagnostic methods yield uncertainty.8 Additionally, MRIs and CT scans can be used to identify further vascular morbidities.1
Treatment and management
Treatment primarily involves managing the underlying venous insufficiency and alleviating symptoms and skin issues with topically acting agents. Management options include:
Lifestyle modifications: Leg elevation, walking, and weight management are recommended in patients with VSD but have been effective only in mild cases.4
Compression therapy: This constitutes the primary approach to VSD, involving the use of bandages or stockings to reduce venous pressure whilst walking and mitigate symptoms such as swelling and epidermal changes.4
Oral medications: Active agents such as pentoxifylline and venotropic drugs are used in patients with VSD to reduce pain and swelling.1 Notably, a specific study on a flavonoid-containing drug, which has a vasoactive action (affecting blood flow through veins) and improves microcirculation, has reported impressive results when used in combination therapies for patients with chronic venous insufficiency.9 Numerous other oral medications are available to alleviate specific symptoms.
Topical treatments and dressings: Bland emollients and moisturisers can manage xeroderma, while topical corticosteroids with high and mild potency may be provided to relieve itching symptoms, though they are not recommended for prolonged use.4 A bandage coated in moist zinc oxide may also be applied topically to reduce the symptoms of inflammation, itching, and eczema.1
Surgical and minimally invasive interventions: Surgical options for addressing ongoing venous hypertension exist but have been largely replaced by methods such as endovenous laser ablation, ultrasound-guided sclerotherapy and ambulatory phlebectomy. These techniques offer rapid recovery, reduced cost, and fewer complications.1
Alternative approaches: Acupuncture is considered an alternative method for relieving various symptoms, such as pain and swelling, due to its anti-inflammatory properties.10,11 A positive association has also been observed with venous ulcers and other skin conditions.12,13 While this procedure shows promising results, further studies are necessary to certify its validity and effectiveness.
In summary, VSD acts as a visible indicator of underlying venous dysfunctions, often linked to venous hypertension and chronic venous insufficiency. If undetected or mistreated, VSD can progress to painful venous ulcers, posing significant risks. The inflammatory state of the skin in VSD is what causes one of the most distressing symptoms, itching, which drastically impacts the quality of life of patients, particularly the elderly.
Thorough symptom evaluation and accurate diagnostic approaches are decisive for determining the disease’s extent and appropriate treatment options. Individuals experiencing symptoms such as leg pain, swelling, itching and skin rashes should not hesitate to consult a health professional.
Other non-conventional treatments, holistic healthcare practices and natural alternatives can be integrated with medical expertise, offering an overall relief in the symptoms and quality of life of affected individuals.
How serious is VSD?
VSD might not be life-threatening on its own, but it serves as an indicator of an underlying vascular dysfunction that requires attention and management. If left untreated or undetected, it may progress to more severe stages and lead to painful venous ulcers. Moreover, VSD substantially impacts the quality of life of elderly patients, due to distressing symptoms like itching and discomfort. Seeking medical attention is strongly advised.
How common is VSD?
VSD is relatively common, especially with ageing, and it exhibits a higher prevalence among women. Given the trend towards more sedentary lifestyles and increasing rates of obesity in many societies, the prevalence of VSD and its closely related condition, chronic venous insufficiency, are anticipated to rise.1 These circumstances highlight the importance of early detection and management of VSD, especially in populations where these risk factors are becoming more prevalent.
Is VSD contagious?
VSD is not contagious.
How to prevent VSD?
While risk factors contribute to VSD development, certain approaches, when aligned with healthcare professional advice, can be effective preventive measures. Adopting a healthier lifestyle, engaging in regular exercising and following a balanced diet are essential steps. Elevating legs and wearing compression stockings, if recommended, can also aid in the prevention of VSD. Medical guidance is essential for determining which preventive approaches are more suitable for each individual.
- Yosipovitch G, Nedorost ST, Silverberg JI, Friedman AJ, Canosa JM, Cha A. Stasis dermatitis: an overview of its clinical presentation, pathogenesis, and management. Am J Clin Dermatol [Internet]. 2023 Mar [cited 2023 Sep 25];24(2):275–86. Available from: https://link.springer.com/10.1007/s40257-022-00753-5
- Weaver J, Billings SD. Initial presentation of stasis dermatitis mimicking solitary lesions: A previously unrecognized clinical scenario. Journal of the American Academy of Dermatology [Internet]. 2009 Dec [cited 2023 Sep 25];61(6):1028–32. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0190962209005052
- Tucker WD, Arora Y, Mahajan K. Anatomy, blood vessels. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Sep 26]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK470401/
- Silverberg J, Jackson JM, Kirsner RS, Adiri R, Friedman G, Gao XH, et al. Narrative review of the pathogenesis of stasis dermatitis: an inflammatory skin manifestation of venous hypertension. Dermatol Ther (Heidelb) [Internet]. 2023 Apr [cited 2023 Sep 26];13(4):935–50. Available from: https://link.springer.com/10.1007/s13555-023-00908-0
- García-Honduvilla N, Asúnsolo Á, Ortega MA, Sainz F, Leal J, Lopez-Hervas P, et al. Increase and redistribution of sex hormone receptors in premenopausal women are associated with varicose vein remodelling. Oxidative Medicine and Cellular Longevity [Internet]. 2018 Sep 3 [cited 2023 Sep 26];2018:1–9. Available from: https://www.hindawi.com/journals/omcl/2018/3974026/
- Ortega MA, Fraile-Martínez O, García-Montero C, Álvarez-Mon MA, Chaowen C, Ruiz-Grande F, et al. Understanding chronic venous disease: a critical overview of its pathophysiology and medical management. JCM [Internet]. 2021 Jul 22 [cited 2023 Sep 26];10(15):3239. Available from: https://www.mdpi.com/2077-0383/10/15/3239
- Rzepecki AK, Blasiak R. Stasis dermatitis: differentiation from other common causes of lower leg inflammation and management strategies. Curr Geri Rep [Internet]. 2018 Dec [cited 2023 Sep 27];7(4):222–7. Available from: http://link.springer.com/10.1007/s13670-018-0257-x
- Sundaresan S, Migden MR, Silapunt S. Stasis dermatitis: pathophysiology, evaluation, and management. Am J Clin Dermatol [Internet]. 2017 Jun [cited 2023 Sep 27];18(3):383–90. Available from: http://link.springer.com/10.1007/s40257-016-0250-0
- Ramelet AA. Clinical benefits of daflon 500 mg in the most severe stages of chronic venous insufficiency. Angiology [Internet]. 2001 Aug [cited 2023 Sep 27];52(1_suppl):S49–56. Available from: http://journals.sagepub.com/doi/10.1177/0003319701052001S07
- Orak Y, Eroğlu E, Baylan FA, Yıldız S, Boran ÖF, Doganer A, et al. Effects of acupuncture on pain and levels of IL-17 and IL-23 in the treatment of non-thermal endovenous ablation: A randomized clinical trial. Vascular [Internet]. 2022;30(3):532–41. Available from: http://dx.doi.org/10.1177/17085381211013980
- Li N, Guo Y, Gong Y, Zhang Y, Fan W, Yao K, et al. The anti-inflammatory actions and mechanisms of acupuncture from acupoint to target organs via neuro-immune regulation. JIR [Internet]. 2021 Dec [cited 2023 Sep 27];Volume 14:7191–224. Available from: https://www.dovepress.com/the-anti-inflammatory-actions-and-mechanisms-of-acupuncture-from-acupo-peer-reviewed-fulltext-article-JIR
- Li X, Xiao Q qing, Ze K, Li S, Wang Y fei, Zhou M, et al. External application of traditional Chinese medicine for venous ulcers: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine [Internet]. 2015 [cited 2023 Sep 27];2015:1–10. Available from: http://www.hindawi.com/journals/ecam/2015/831474/
- Hwang J, Lio PA. Acupuncture in dermatology: an update to a systematic review. The Journal of Alternative and Complementary Medicine [Internet]. 2021 Jan 1 [cited 2023 Sep 27];27(1):12–23. Available from: https://www.liebertpub.com/doi/10.1089/acm.2020.0230