Every year, about 150,000 people are diagnosed with stasis dermatitis, a skin disorder caused by vascular dysfunction. Also called gravitational dermatitis, venous eczema, or varicose eczema, stasis dermatitis is an inflammatory skin disorder that most commonly affects adults over the age of 50.
The risk of stasis dermatitis increases with age, and there is a strong possibility that you may be affected by this disorder–either as a patient or family member. As prevalent as it is, patients often fail to recognize early symptoms of stasis dermatitis, and it is sometimes misdiagnosed. This type of dermatitis can have serious complications, though, so understanding its causes, symptoms and treatments is useful.
What Is Stasis Dermatitis?
Stasis dermatitis is a form of eczema. Like any other kind of eczema, inflammation and skin barrier dysfunction are hallmarks of stasis dermatitis.
This type of dermatitis, though, is not associated with allergy or poor synthesis of skin barrier proteins. Instead, it is caused by dysfunction of the blood vessels in the extremities.
Prevalence and Demographics
Stasis dermatitis affects approximately 1 in 20 Americans. It most commonly affects people ages 50 and older: About 15 to 20 million people in this age group in the U.S. have this condition. Stasis dermatitis affects women more than men, and correlates with venous insufficiency and varicose veins. Anyone with age-related leg swelling will eventually be at risk for stasis dermatitis. Complications from Stasis dermatitis cause thousands of hospitalizations every year. It can lead to amputation in extreme cases.
“Preventing stasis dermatitis hospitalizations is where American Medicine has made some of the least progress,” board-certified dermatologist Dr. Steve Harlan tells us.
Causes of Stasis Dermatitis
Stasis dermatitis is caused by abnormal blood flow returning from the legs. It is a sign of chronic venous insufficiency (CVI), a condition in which the veins can no longer move blood back to the heart efficiently, and the legs swell with edema. It’s often hereditary.
Veins have valves, which keep the blood flowing up to the heart. Weight gain and inherited weak or damaged vein valves is a common factor in 50 year olds. Aging support tissues and reduced heart functions is a common factor after age 75. This venous insufficiency and stasis damages blood vessels and triggers inflammation and more swelling.
Chronic venous insufficiency is the result of damage to the veins. It can be classified as primary, arising from defects in the wall of the vein, or secondary, resulting from an event such as deep venous thrombosis (DVT) that damages venous valves.
Normally, your veins pump blood upward to your heart so that it can be reoxygenated and recirculated. When the walls or valves of the veins do not function properly, an efficient upward flow of blood cannot occur. The resulting backflow causes the blood to pool in the extremities.
This pooling of blood and fluid in the legs is known as stasis–this is where stasis dermatitis gets its name. Stasis results in abnormal pressure on the walls of the veins. As a result, red blood cells pass through the walls of the vein and begin to break down, staining the skin with what’s called “hemosiderin.”
As the blood cells break down, they trigger an immune system response. Molecules such as white blood cells, interleukins, and matrix metalloproteinases go to work to address these out-of-pocket blood cells. Because the damaged red blood cells and their products have nowhere to go, the immune system continues unabated. The result is chronic inflammation, visible as stasis dermatitis.
Matrix metalloproteinases (MMPs) in particular appear to play a leading role in the development of stasis dermatitis. Under normal circumstances, MMPs help to stimulate and sustain wound healing. They change the extracellular matrix surrounding cells, allowing for accelerated cell production and migration–very helpful when damaged cells need to be replaced.
Iron ions left behind by red blood cell breakdown signal for increased MMP production. The MMPs upregulate the production of pro-inflammatory molecules. Tissue studies suggest that MMPs “remodel” skin cells abnormally, resulting in eczema lesions.
Not everyone with CVI will develop stasis dermatitis, but CVI is the unifying cause of stasis dermatitis. Any predisposition to CVI increases the risk of stasis dermatitis.
Age-related vein damage, hypertension (high blood pressure), heart disease, and kidney disease are common risk factors. Other risk factors include varicose veins, obesity and lack of exercise. Jobs requiring long periods of standing can affect vein health. Parity (the number of pregnancies a patient has had) also influences the development of CVI.
Some risk factors can be inherited. This includes hereditary connective tissue disorders. Inherited mutations on the FOXC2 gene, which regulates the development of venous and lymphatic valves, is a predisposing factor in venous valve failure, varicose veins, and CVI.
Symptoms and Diagnosis
Stasis dermatitis (SD) most often presents in the legs, although it can occur in other extremities. Typically, symptoms begin on the inside of the ankle, spreading upwards along the shin as the condition worsens.
A gradually worsening (insidious) itch is usually the first symptom of SD. Patients often do not seek care for this itch when it begins. Conditions often worsen by the time the symptoms bother patients enough to see a doctor. At the clinic, SD patients usually present with poorly demarcated patches of dry, red skin with scaling.
Other signs include pain, lichenification (thickening of the skin from rubbing), and discoloration.
Fair-skinned patients may have scattered, brown speckles and patches in the affected area; these spots may be purplish in darker skin. These are the deposits of hemosiderin, a brown, iron-rich pigment left behind as red blood cells outside of the veins break down. While symptoms usually start at the ankle, skin changes have often spread downward to the foot and/or upward to the knee by the time patients visit a doctor.
Itch is frequently the most troublesome symptom for patients, with increasingly deleterious effects on their quality of life. Many people present to their doctor with numerous small scabs and wounds from scratching their red tense swollen skin. This is a worrying sign for doctors, as scratching often leads to complications such as infection.
Stasis dermatitis can mimic other skin disorders, including cellulitis (a skin infection), contact dermatitis, and atopic dermatitis. An experienced dermatologist can make a differential diagnosis.
The dermatologist will take an extensive medical history, noting any risk factors for stasis dermatitis. They will then examine the skin. If visual examination leaves uncertainties about the diagnosis, the dermatologist may order a patch test to see if skin lesions are caused by allergy.
They may culture skin samples for staph or other bacterial infections, because these infections can both mimic stasis dermatitis and occur secondary to it. Infrequently, blood tests may be ordered if infection is suspected.
Occasionally, a biopsy of the affected skin may be ordered. Hemosiderin deposits (also known as hemosiderin staining and hemosiderin hyperpigmentation) are a sign of stasis dermatitis, but they can look similar to melanin deposits. Stains of biopsy samples can distinguish between the two.
Ultrasounds may be used to examine blood vessels and determine where blood flow may be inadequate.
Complications With Stasis Dermatitis
“Stasis dermatitis is the number one skin problem that leads to hospitalization,” Dr. Harlan says,
“and most of the time it was preventable.”
Stasis dermatitis lesions often become infected due to scratching. A common early version of this is “impetiginized skin” loaded with staphylococcal and streptococcal bacteria. These conditions can progress to either cellulitis or erysipelas, depending upon the depth of the infection. Erysipelas infections are more patchy and superficial; they are less common. Far more commonly, the leg infections are called cellulitis.
Cellulitis is a hot and painful, usually one-sided development. Fever is a more serious sign, as is a red streak coming up the leg. Cellulitis needs immediate medical attention. Stasis dermatitis without infection is red, itching, flared by swelling, and often present to some degree on both legs.
Severe, long-standing stasis dermatitis leads to ulcers and open wounds, and to “elephant hide-like” thickening of the leg skin, and/or thickened, firm cobblestone-like areas of the lower legs. Some stasis dermatitis patients develop acroangiodermatitis (pseudo–Kaposi sarcoma), a condition that causes the proliferation of small blood vessels.
The Clinical-Etiology-Anatomy-Pathophysiology (CEAP) is a classification tool for CVI. It indicates the degree to which the effects of CVI can be observed.
Scores for CEAP classification range from C0, meaning that no venous disease can be seen or felt on exam, to C6, which indicates observable ulceration of the vein. Stasis dermatitis is classified as C4, meaning that changes in the skin secondary to CVI can be observed.
While venous ulceration is not in and of itself a complication of stasis dermatitis, a diagnosis of stasis dermatitis indicates more significant venous damage and a greater risk of ulceration. Those with stasis dermatitis should report any signs of ulceration to their doctor as soon as possible.
Stasis dermatitis is chronic, and the damage done by CVI is often irreversible and permanent. Most treatment centers around alleviating symptoms, preventing swelling (edema), and preventing further vascular damage. Elevating the legs and using compression stockings or bandages can help prevent venous backflow and take some of the pressure off of the blood vessels. Dermatitis symptoms are addressed with anti-inflammatory treatments (such as topical corticosteroids) and antihistamines (to alleviate itch).
Dr. Harlan treats his stasis dermatitis patients by first having them apply an eczema cream such as SmartLotion® three times a day for up to 3 weeks. He also insists that they apply moisturizer two times a day at a minimum.
Newly-flared edema patients often are too swollen to use compression hose. They should elevate the legs for a few days and use Ace wraps, 4 or 6 inches wide. Applying Ace wraps, propping the legs up on pillows, and mimicking the action of a recumbent bicycle is the fastest home remedy, according to Dr. Harlan.
Very soon, the knee-high elastic hose can be used all day. Dr. Harlan recommends wrapping with two Ace wraps on each leg from the toes to the knees, and he advises patients to keep their legs elevated as much as possible.
Using a facility’s recumbent bicycle is of course excellent for reducing fluid in the legs. Dr. Harlan tells us that this strategy is effective for most of his stasis dermatitis patients, with most of them seeing marked improvement within 3 weeks with no further prescription treatment.
In severe cases, minor surgery to superficial veins can alleviate backflow and stasis. A more significant procedure is now being tested at Yale, involving the implantation of a small frame containing a pig’s cardiac valve in the femoral vein.
Taking Control of Stasis Dermatitis
Stasis dermatitis affects many people, interfering with their quality of life and predisposing them to serious complications. Stasis dermatitis patients can reduce their risk of developing complications and alleviate symptoms such as itch with a good self-care strategy. This could include any combination of the following:
Using wraps or compression stockings as indicated.
Gentle skin cleansing followed by moisturizing to prevent dry scaly skin.
Elevating the legs as much as possible and avoiding sitting or standing for long periods of time.
Regular use of a recumbent bike.
Applying cool compresses to itching skin for a few minutes
Applying an over-the-counter steroid cream, such as SmartLotion®.
Dr. Harlan created SmartLotion® with the needs of his chronic dermatitis
patients in mind, so it can be applied it as needed without risk of topical
steroid withdrawal or skin atrophy (common side effects
associated with long-term use of high-powered corticosteroids).
Dr. Harlan says that this gives his patients a greater degree of control over their symptoms.
- Moisturizing regularly with a dermatologist-recommended moisturizing cream. Ideally, patients should moisturize at least twice a day, using a cream that contains ingredients such as natural ceramides, glycerin and healing oils, as well as prebiotics that support the skin barrier.
HarlanMD Perfect Repair™ cream is another breakthrough. Its ingredients include natural ceramides and chia seed extract which bolster the skin barrier and prevent moisture loss.
It also contains coconut oil, which has recently been recognized for its powerful eczema-healing properties. Jojoba oil and glycerin support the health of the skin’s microbiome. It contains no methylisothiazolinone nor propylene glycol.
- Staying connected with your healthcare providers, including your dermatologist as well as any other specialists helping you manage CVI, such as cardiologists, lymphedema clinics, and wound care clinics. Report new or worsening symptoms, as this could signify an increased risk of venous ulceration. All these will help you stay out of the hospital.
Stasis dermatitis should be taken seriously. It causes an inordinate amount of entirely preventable hospitalizations. However, good healthcare and supportive home care can keep it manageable in most cases.
I've you've enjoyed and found our article on Stasis Dermatitis useful, you can find more in depth articles on skincare care and conditions throughout our blog.
Steven Harlan MD
Board Certified Dermatologist
Inventor of SmartLotion®