eMedicine Specialties > Dermatology > Diseases of the Vessels

Stasis Dermatitis: Treatment & Medication

Author: Scott L Flugman, MD, Consulting Staff, Dermatology Associates of Huntington PC
Coauthor(s): Richard A Clark, MD, Professor of Biomedical Engineering, Dermatology and Medicine, Director of Center of Tissue Engineering, State University of New York at Stony Brook
Contributor Information and Disclosures

Updated: Mar 23, 2009

Treatment

Medical Care

  • Compression therapy13,14
    • Although extensive work has been completed in the study of treatment of venous ulcers, no large, well-controlled trials examine the treatment of stasis dermatitis. The overall mainstay of treatment has always been aimed at lessening the clinical impact of the underlying venous insufficiency, which is typically accomplished with compression therapy. Assessing the patient's peripheral arterial circulation (clinically or with a Doppler study) before recommending compression therapy is important; adding compression to a leg with compromised arterial circulation could increase claudication and put the patient at risk for ischemic damage.
    • Compression is generally accomplished by means of specialized stockings that deliver a controlled gradient of pressure (measured in mm Hg) to the affected leg. More aggressive compression can be performed by using elastic wraps; compression (Unna) boots; and more sophisticated devices, such as end-diastolic compression boots. Most of these modalities require administration in a physician's office or wound care center. Frequent leg elevation is a necessary adjunct to leg compression.
    • Counseling patients regarding the use of compression therapy is vital to successful management of stasis dermatitis. Patients frequently resist the idea of compression dressings and/or stockings because these modalities may cause considerable discomfort when first applied to edematous, inflamed lower extremities. However, it is important to reassure patients that this discomfort will lessen considerably as leg edema is reduced, and this therapy must be maintained permanently in order to prevent a recurrence of dermatitis and leg ulcers. Compression stockings should be applied early in the morning, before the patient rises from bed, in order to facilitate application when leg edema is at its lowest point.
  • Topical therapy15,16
    • Topical treatment of stasis dermatitis has much in common with the treatment of other forms of acute eczematous dermatitis. Weeping lesions can be treated with wet-to-damp gauze dressings soaked with water or with a drying agent, such as aluminum acetate. Topical corticosteroids are frequently used for reducing inflammation and itching in acute flares; mid-potency corticosteroids, such as triamcinolone 0.1% ointment, are generally effective.
    • Be wary of the use of high-potency topical corticosteroids in stasis dermatitis because the chronically inflamed skin can increase the risk of systemic absorption and because steroid-induced cutaneous atrophy can predispose the patient to ulceration.17,18 Furthermore, prolonged use of topical steroids can lead to decreased efficacy of the steroid, a phenomenon known as tachyphylaxis. Systemic corticosteroids are not part of stasis dermatitis treatment, although they may be required in very severe cases of widespread autoeczematization.
    • The recently approved nonsteroidal calcineurin inhibitors tacrolimus and pimecrolimus may prove to be useful tools in the management of stasis dermatitis. Although these topical medications are approved only for atopic dermatitis, they have been shown to be effective in many steroid-responsive dermatoses. Because the calcineurin inhibitors do not carry the risks of skin atrophy or tachyphylaxis, they have the potential to become valuable agents in the treatment of chronic dermatoses such as stasis dermatitis.
  • Prevention/management of infection
    • Be wary of infection in stasis dermatitis; this becomes more problematic when using topical corticosteroids, which make the patient more susceptible to infection.
    • Open excoriations and erosions should be treated with a topical antibiotic, such as bacitracin or Polysporin. Obvious superficial impetiginization should be treated with topical mupirocin or a systemic antibiotic with activity against Staphylococcus and Streptococcus species (eg, dicloxacillin, cephalexin, cefadroxil, levofloxacin).
    • Culture with sensitivity testing is important when managing suspected superinfection because community-acquired methicillin resistance is becoming increasingly prevalent.
    • Expanded coverage may be necessary in patients who are immunocompromised.
    • Suspected deep cellulitis should always be treated with oral or intravenous antibiotics. Necrotizing fasciitis would be a rare complication but is a surgical emergency.
  • Complications of treatment - Allergic contact dermatitis
    • The development of contact dermatitis is especially problematic in the treatment of patients with stasis dermatitis. Chronic inflammation of the skin, coupled with the use of multiple topical medications (both prescription and over-the-counter) frequently result in contact sensitization as a complication of stasis dermatitis. Patients should be instructed to not apply over-the-counter antibiotics or other topical agents without the direction of a physician.
    • Some of the most frequent contact allergens complicating stasis dermatitis include the topical antibiotics neomycin and bacitracin. In addition, affected patients may become sensitized to rubber products that are found in some wraps and stockings. Topical corticosteroid allergy, while uncommon, is a condition that can worsen stasis dermatitis despite seemingly appropriate prescription therapy.
    • Consider contact dermatitis in any patient with stasis dermatitis who becomes clinically worse despite appropriate topical treatment.
  • Long-term management
    • Patients with chronic, quiescent stasis dermatitis can be treated with bland topical emollients to maximize epidermal moisture.
    • Plain white petrolatum is an inexpensive occlusive moisturizer that is very effective and, importantly, does not contain any contact sensitizers.

Surgical Care

Stasis dermatitis related to an arteriovenous fistula or incompetent perforators may respond to ligation of the vessels.  Hemosiderin may show some response to treatment with a noncoherent intense pulsed light source.19

Consultations

Uncomplicated stasis dermatitis is usually managed in the dermatologist's office.

  • A consultation with a vascular surgeon may be required, especially when an underlying surgically correctable vascular abnormality is suspected.
  • A consultation with a hematologist may be needed when treating a patient with stasis dermatitis due to deep venous thrombosis; cases such as these may be secondary to congenital or acquired hypercoagulable states.

Medication

Recent new theories regarding the pathogenesis of cutaneous inflammation in venous insufficiency have led to the investigation of systemic therapies, which have been hypothesized to have beneficial modulating effects on neutrophil function. Treatments, such as prostaglandin E1 (PGE1) and pentoxifylline, have been studied in the treatment of venous ulcers; it is hypothesized that these medications decrease cytokine-mediated neutrophil activation, leading to reduced inflammation.20 However, even if these systemic therapies are proven unequivocally effective, it is unlikely that their use will extend beyond the scope of treatment of recalcitrant venous ulcers.

More on Stasis Dermatitis

Overview: Stasis Dermatitis
Differential Diagnoses & Workup: Stasis Dermatitis
Treatment & Medication: Stasis Dermatitis
Follow-up: Stasis Dermatitis
Multimedia: Stasis Dermatitis
References
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References

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Further Reading

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Keywords

stasis dermatitis, venous ulcer, venous eczema, chronic venous insufficiency, venous hypertension

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Contributor Information and Disclosures

Author

Scott L Flugman, MD, Consulting Staff, Dermatology Associates of Huntington PC
Scott L Flugman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Richard A Clark, MD, Professor of Biomedical Engineering, Dermatology and Medicine, Director of Center of Tissue Engineering, State University of New York at Stony Brook
Richard A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Academy of Dermatology, American Association for the Advancement of Science, American Dermatological Association, American Society for Clinical Investigation, Association of Clinical Scientists, New York Academy of Medicine, Society for Investigative Dermatology, and Wound Healing Society
Disclosure: Nothing to disclose.

Medical Editor

Jean-Hilaire Saurat, MD, Chair, Professor, Department of Dermatology, University of Geneva, Switzerland
Jean-Hilaire Saurat, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Richard P Vinson, MD, Assistant Clinical Professor, Department of Dermatology, Texas Tech University School of Medicine; Consulting Staff, Mountain View Dermatology, PA
Richard P Vinson, MD is a member of the following medical societies: American Academy of Dermatology, Association of Military Dermatologists, Texas Dermatological Society, and Texas Medical Association
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey Meffert, MD, Assistant Clinical Professor of Dermatology, University of Texas Health Science Center-San Antonio
Jeffrey Meffert, MD is a member of the following medical societies: American Academy of Dermatology, American Medical Association, Association of Military Dermatologists, and Texas Dermatological Society
Disclosure: Nothing to disclose.

CME Editor

Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania
Joel M Gelfand, MD, MSCE is a member of the following medical societies: Society for Investigative Dermatology
Disclosure: AMGEN Consulting fee Consulting; AMGEN Grant/research funds None; Genentech Consulting fee Consulting; Centocor Consulting fee Consulting; Centocor Grant/research funds None; Covance Consulting fee Consulting; Shire  Consulting

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
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