Stasis Dermatitis Treatment & Management

Although extensive work has been completed in the study of venous ulcer treatment, no large, well-controlled trials have examined the treatment of stasis dermatitis. The overall mainstay of treatment has always been aimed at lessening the clinical impact of the underlying venous insufficiency and edema, a goal that is typically accomplished with high-level compression therapy. ^{[29, 30]}

Inpatient treatment

Stasis dermatitis is typically managed in the dermatologist's office, and it does not require inpatient admission. However, it is common for patients to be admitted to hospitals for stasis dermatitis. Admission may occur because their condition becomes exacerbated, and the discomfort, itching, and swelling becomes too difficult for the patient to manage at home. It is likewise a common occurrence that patients with exacerbating stasis dermatitis are admitted to hospital services with a misdiagnosis of cellulitis. Although it may be difficult to rule out cellulitis in a patient with flaring stasis dermatitis, the presence of "bilateral cellulitis" is in most cases a bilateral exacerbation of stasis dermatitis. Considering the chronic nature of stasis dermatitis and the difficulty many patients have with complying with treatment regimens, readmissions for stasis exacerbations may be frequent. Some authors have seen reduction of hospital readmissions by the use of a stasis dermatitis order set for admitted patients. This method can standardize admitting orders to include dermatologic consultation, patient education, and training in the use of support stockings by physical therapy. ^[31]

Ligation

Stasis dermatitis related to an arteriovenous fistula or incompetent perforators may respond to ligation of the vessels.

Light

Combination therapy with autologous platelet-rich plasma and light-emitting diodes shows some promise in the treatment of refractory stasis ulcers. ^[32]

Skin discoloration

Stasis pigmentation, resulting from hemosiderin deposition, is notoriously difficult to treat and typically does not resolve even when the underlying stasis dermatitis is well controlled with topical therapy. For patients who are bothered by the cosmetic appearance of stasis pigmentation, the use of concealing cosmetic products is frequently the best option. However, some authors have reported improvement of stasis pigmentation after treatment with a noncoherent intense pulsed light (IPL) source. ^[33]

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. ^[34]

Compression accomplished by means of specialized stockings that deliver a controlled pressure gradient (measured in mm Hg) to the affected leg are suitable for long-term management of edema, but not for healing of stasis 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.

High-level 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.

Grafting

Allogeneic cultured dermal substitutes have been used, but are expensive. Most patients respond to high-level compression alone. ^[35]

Patient compliance

Counseling patients regarding the use of compression therapy is vital to the successful management of stasis dermatitis. Although the benefits of compression therapy are widely recognized, patient noncompliance with regard to compression stockings remains a major barrier to treatment. Difficulty in stocking application and patient concerns about appearance are among the reasons why patients may fail to comply with this therapy. ^[36]

In addition, patients frequently resist the idea of using 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 the discomfort lessens considerably as leg edema is reduced and to inform them that this therapy must be maintained permanently in order to prevent a recurrence of dermatitis and leg ulcers.

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 to reduce inflammation and itching in acute flares; midpotency corticosteroids, such as triamcinolone 0.1% ointment, are generally effective. ^{[37, 38]}

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. ^{[39, 40]} Furthermore, prolonged use of topical steroids can cause their efficacy to decrease, 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.)

Nonsteroidal treatment

The 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.

A single-arm, interventional pilot study by Maroo et all indicated that combination therapy with topical tacrolimus and oral doxycycline may be effective against stasis dermatitis. The study evaluated treatment results in 15 patients with stasis dermatitis resulting from chronic venous insufficiency in the lower limbs. The patients were treated for 4 weeks with topical tacrolimus 0.1% and oral doxycycline 100 mg. ^[41]

The investigators found that 86.6% of the patients demonstrated improvement of the dermatitis area, while 6.7% showed no improvement, and another 6.7% experienced worsened dermatitis. Two patients showed adverse effects.

The researchers also found that patients had significant improvement in pain, edema, erythema, pigmentation, and exudation, as well as a statistically significant reduction in ulcer size.

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.

Also see the guideline for venous ulcer care from the Association for the Advancement of Wound Care.

Based on theories regarding the pathogenesis of cutaneous inflammation in venous insufficiency, systemic therapies that have been hypothesized to have beneficial modulating effects on neutrophil function have been investigated.

Treatments that have been studied for venous ulcers, such as prostaglandin-E1 (PGE1) and pentoxifylline therapies, have been hypothesized to decrease cytokine-mediated neutrophil activation, leading to reduced inflammation. ^[42] However, even if these systemic therapies are proven to be unequivocally effective, it is unlikely that their use will extend beyond the scope of treatment of recalcitrant venous ulcers.

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.

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 (prescription and over-the-counter), frequently results in contact sensitization as a complication of stasis dermatitis. In addition, patients may become sensitized to rubber products found in some wraps and stockings.

Some of the most frequent contact allergens complicating stasis dermatitis include the topical antibiotics neomycin and bacitracin. Patients should be instructed against applying over-the-counter antibiotics or other topical agents without the direction of a physician.

Products based on the antimicrobial agent triclosan have been shown to present a low risk for contact sensitization in patients with stasis dermatitis. These products may be a good alternative to decrease bacterial colonization, especially in patients who have a history of cellulitis or other cutaneous infections. ^[43]

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.

Stasis dermatitis is a chronic condition. Acute exacerbations of this disorder should be closely monitored with weekly office visits, with careful observation for signs of infection. However, patients with long-standing stasis dermatitis may be able to manage the disease on their own with the use of compression stockings, elevation, proper skin care, and short courses of topical steroids for inflammatory exacerbations. The clinician must be vigilant in treating any signs of cutaneous ulceration with close follow-up care to ensure that ulceration does not become a chronic problem.

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