History
Patient history may reveal the following:
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Pruritus - Patients with stasis dermatitis typically present with an insidious onset of pruritus affecting 1 or both lower extremities
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Discoloration - Reddish-brown skin discoloration is an early sign of stasis dermatitis and may precede the onset of symptoms
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Ankle involvement - The medial ankle is most frequently involved, with symptoms progressing to involve the foot and/or calf
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Edema - Stasis dermatitis patients may offer a prior history of dependent leg edema
Isoda et al reported a case of stasis dermatitis resulting from an artificial arteriovenous fistula that was created in the patient 33 years previously, during treatment for poliomyelitis. [22]
Factors that worsen peripheral edema (eg, congestive heart failure, long-standing hypertension with diastolic dysfunction) are often found in patients with stasis dermatitis. Some antihypertensive medications (such as amlodipine) may increase leg edema and trigger the onset of stasis dermatitis. [23]
Physical Examination
Physical examination in stasis dermatitis patients reveals erythematous, scaling, and eczematous patches affecting the lower extremity.
The medial ankle is most frequently and severely involved, a result of the fact that it represents a watershed area with relatively poor blood flow compared with the rest of the leg. In advanced cases of stasis dermatitis, the inflammation may encircle the ankle and extend to just below the knee; this is sometimes referred to as stocking erythroderma. The dorsal part of the foot may be involved in severe cases.
A solitary, small patch of stasis dermatitis may mimic basal cell carcinoma or squamous cell carcinoma. [24]
Secondary infection can cause typical honey-colored crusting due to bacteria or can produce monomorphous pustules due to cutaneous candidiasis.
Eczematous changes
Involved skin in stasis dermatitis may exhibit changes seen in other eczematous conditions. Severe, acute inflammation may result in exudative, weeping patches and plaques. Underlying fat necrosis (lipodermatosclerosis) may be exquisitely painful; these cases of deep, acute inflammation may be difficult to differentiate from cellulitis or erythema nodosum. In fact, stasis dermatitis is the most frequent condition for which patients are admitted unnecessarily with the misdiagnosis of cellulitis. [25, 26, 27]
Chronic disease
In long-standing lesions, lichenification and hyperpigmentation may occur as a consequence of chronic scratching and rubbing. In addition, patients with chronic stasis dermatitis can show changes, such as skin induration, that may progress to lipodermatosclerosis (with the classic inverted champagne bottle appearance). [28]
Another unique feature sometimes seen in chronic stasis dermatitis is the development of violaceous plaques and nodules on the legs and the dorsal part of the feet. These lesions frequently undergo painful ulceration and can be clinically indistinguishable from classic Kaposi sarcoma. This clinical appearance has led this entity to be called pseudo–Kaposi sarcoma or acroangiodermatitis.
Signs of venous insufficiency
Stasis dermatitis frequently occurs along with a background of skin changes that are typical for patients with venous insufficiency (and that persist regardless of the activity of stasis dermatitis). These changes include the following (see the images below):
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Edema
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Varicosities
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Hyperpigmentation
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Atrophic patches (atrophie blanche)
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Diffuse, red-brown discoloration representing deep dermal deposits of hemosiderin (from degraded, extravasated erythrocytes)
This patient exhibits the classic hyperpigmentation and varicosities of stasis dermatitis. There is inflammatory eczematous change overlying the medial ankle, with healed scarring from recent ulceration.
This patient with chronic stasis dermatitis exhibits classic features, such as erythema, hyperpigmentation, and dilated superficial veins reflecting poor function of the deep venous system. The condition is typically confined to the lower leg, particularly the medial portion of the leg.
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This patient exhibits the classic hyperpigmentation and varicosities of stasis dermatitis. There is inflammatory eczematous change overlying the medial ankle, with healed scarring from recent ulceration.
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This patient with chronic stasis dermatitis exhibits classic features, such as erythema, hyperpigmentation, and dilated superficial veins reflecting poor function of the deep venous system. The condition is typically confined to the lower leg, particularly the medial portion of the leg.
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Patient with stasis dermatitis. The large scar on the calf resulted from military shrapnel. Injuries to the venous system due to trauma or surgery are common factors in the development of stasis dermatitis.
