Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications. Midpotency corticosteroids, such as triamcinolone 0.1% ointment, are generally effective in reducing the inflammation and itching of acute flares of stasis dermatitis. [37, 38] However, the clinician should be wary of using high-potency topical corticosteroids in stasis dermatitis; the chronically inflamed skin can increase the risk of systemic absorption and steroid-induced cutaneous atrophy can predispose the patient to ulceration. [39, 40]
Infection is a particular concern in stasis dermatitis, since topical corticosteroids make the patient more susceptible to infection. Open excoriations and erosions should be treated with a topical antibiotic.
Corticosteroids
Class Summary
These agents elicit anti-inflammatory and immunosuppressive properties.
Triamcinolone topical (Oralone, Triderm, Zytopic, Kenalog)
Triamcinolone topical is a moderate-potency steroid with anti-inflammatory properties. It treats inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing the migration of polymorphonuclear leukocytes and reversing capillary permeability.
Antibiotics, Other
Class Summary
These are used to treat open excoriations and erosions. 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).
Bacitracin (Baci-IM, Baciguent)
Bacitracin prevents the transfer of mucopeptides into the growing cell wall, which causes inhibition of bacterial cell wall synthesis.
Bacitracin and polymyxin B (Polysporin, Polycin, AK-Poly-Bac)
Bacitracin prevents transfer of mucopeptides into the growing cell wall, which causes inhibition of bacterial cell wall synthesis. Polymyxin B damages the bacterial cytoplasmic membrane and alters permeability, causing intracellular constituents to leak. This agent is used to treat open excoriations and erosions.
Mupirocin (Bactroban, Centany)
Mupirocin inhibits bacterial protein synthesis by binding to isoleucyl transfer-RNA synthetase.
Dicloxacillin
Dicloxacillin is used in the treatment of infections caused by penicillinase-producing staphylococci. It may be used as initial therapy when staphylococcal infection is suspected.
Cephalexin (Keflex)
Cephalexin is a first-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. It has bactericidal activity against rapidly growing organisms. It has primary activity against skin flora and is used for skin infections or prophylaxis in minor procedures.
Levofloxacin (Levaquin)
Levofloxacin inhibits DNA gyrase and topoisomerase IV, resulting in bactericidal activity. It is used as an alternative agent for MRSA infection.
Cefadroxil
Cefadroxil is a first-generation semisynthetic cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. It has bactericidal activity against rapidly growing organisms, including S aureus, S pneumoniae, S pyogenes, Moraxella catarrhalis, E coli, Klebsiella species, and Proteus mirabilis.
Topical Immunomodulators
Class Summary
These agents modify immune processes that promote inflammation.
Pimecrolimus (Elidel cream)
Pimecrolimus is indicated for eczema and atopic dermatitis. It was the first nonsteroid cream approved in the United States for mild-to-moderate atopic dermatitis. Pimecrolimus is derived from ascomycin, a natural substance produced by fungus Streptomyces hygroscopicus var ascomyceticus.
This agent selectively inhibits production and release of inflammatory cytokines from activated T cells by binding to cytosolic immunophilin receptor macrophilin-12. The resulting complex inhibits phosphatase calcineurin, thus blocking T-cell activation and cytokine release.
Cutaneous atrophy was not observed in clinical trials, a potential advantage over topical corticosteroids.
Tacrolimus ointment (Protopic) 0.1% or 0.03%
Tacrolimus reduces itching and inflammation by suppressing release of cytokines from T cells. It also inhibits transcription for genes that encode interleukin (IL)–3, IL-4, IL-5, granulocyte-macrophage colony-stimulating factor (GM-CSF), and tumor necrosis factor–alpha (TNF-alpha), all of which are involved in the early stages of T-cell activation.
Additionally, tacrolimus may inhibit release of preformed mediators from skin mast cells and basophils and may down-regulate expression of the high-affinity IgE receptor (FCeRI) on Langerhans cells.
Tacrolimus can be used in patients as young as 2 years. It is more expensive than topical corticosteroids. This agent is available as ointment in concentrations of 0.03% and 0.1%.
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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.
