Managing venous eczema in primary care
Venous eczema management is a holistic approach.
Venous eczema
Venous eczema is also known as varicose or gravitational eczema and is common, affecting 20% of people over 70 years of age.1 Venous hypertension of the lower legs is the central cause of skin changes related to chronic venous disease. The NICE Clinical Knowledge Summary (CKS) states that the exact pathophysiology is unclear, but it is probably due to leakage of blood constituents into the surrounding tissues, with subsequent activation of inflammatory cells and fibroblasts.1 A study confirms this theory by discovering that activated leucocytes release fibrogenic cytokine (TGFb1) which stimulates production of collagen cumulating in dermal fibrosis. The study showed that lower calf skin from a patient with chronic venous disease contained significantly elevated levels of active fibrogenic cytokine (TGFb1).2 Skin changes due to chronic venous disease vary in severity from mild pigmentation, inflammatory eczema to lipodermatosclerosis or atrophie blanche, which has a classification system for clinicians. The risk for patients of venous ulceration increases as the skin condition worsens.
Figure 1: Venous eczema (Wikimedia Commons, public domain)
Table 1: Comprehensive Classification System for Chronic Venous Disorders (CEAP).3
|
CEAP classification of chronic venous disease |
Clinical classification |
|
C0 |
No visible or palpable signs of venous disease |
|
C1 |
Telangiectasias or reticular veins |
|
C2 |
Varicose veins |
|
C3 |
Oedema |
|
C4a |
Pigmentation or eczema |
|
C4b |
Lipodermatosclerosis or atrophie blanche |
|
C5 |
Healed venous ulcer |
|
C6 |
Active venous ulcer |
Diagnosis
Diagnosis of venous eczema is made by clinical assessment and examination only. Investigations for diagnosis are not required, but ankle-brachial pressure index (ABPI) measurements should be considered if suspicion of concurrent arterial disease or would be a necessity if compression hosiery is recommended.
Careful history taking can identify contributing factors, including a history of DVT, cellulitis of lower leg(s), varicose veins, previous leg ulcers, varicose vein surgery or chronic leg swelling aggravated by hot weather or prolonged standing.1,4 Other non-leg related contributing factors include advancing age, being overweight/obese and immobility.1
Table 2: Typical appearance/symptoms of skin changes for diagnosis.1
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