Download Dermatology – Morphology and Acne

Venous Stasis Dermatitis
Kenneth T. Kircher, DO FAOCD
Advanced Dermatology, PLLC
Stasis Dermatitis (SD)
• An inflammatory process (eczematous)
– Acute, subacute or chronic
• Occurs on lower legs
• Setting of venous insufficiency(VI)
– Poor flow of venous and lymphatic fluid from the
legs and feet to the central circulation
– Many contributing factors
• May be accompanied by ulceration
Anatomy and Physiology
• Three types of vessels
– Arteries – high pressure, muscular wall
– Veins – low pressure, check valves, thin wall
– Lymphatics – low pressure, check valves, very
thin wall
• The problem – humans are bipedal / gravity
– Veins and lymphatics rely on the pulsatile nature
of arteries and the compressive action of muscle
contraction to keep fluid moving up hill from
check valve to check valve
Disruption of Homeostatic Balance
• Damage to veins and/or lymphatics
– DVT, damage to valves/varicosities, trauma, DM
• Medications
– Calcium channel blockers
• Age related / social
– Immobility, sedentary, sleeping in a chair
• Total body fluid over load
– CHF, renal failure, thyroid disease, others
Role of Venous Insufficiency (VI)
• Rarely purely venous or lymphatic
• Pooling of the blood in the veins
– Increases the hydrostatic pressure
– Fluid component of blood leaks into surrounding
tissue causing edema (+/-pitting)
– There is a decrease in the O2 tension in tissue
– Many factors precipitate inflammation (fibrin)
– Cells of the skin are less healthy (in a milleu of
increased waste and lower O2)
Moderate edema with mild stasis changes
Finally… Stasis Dermatitis
• VI causes inflammation in the skin and soft
tissue
• Compromised skin more susceptible to
drying, irritation and trauma
– Micro breaks - increased allergy to topical agents
• ? Allergic response to an epidermal protein
– Created from increased hydrostatic pressure
Allergy to Topical Agents
• More likely to have a positive patch test to
topical products
• Common allergens
– Lanolin, benzocaine, parabens, neomycin,
bacitracin (these should be avoided)
– Possible topical steroid allergy
Stages of Eczematous
Inflammation
• Acute, subacute and chronic
• Do not have to develop in order
• Different clinical appearances
Acute Inflammation
• Tends to be more sudden in onset
• May mimic cellulitis
• Boggy, +/-vesicle formation (poison ivy)
– Often weeps and crusts (yellowish serous
exudate)
• May be accompanied by Id reaction
– eczematous rash with +/-vesicles on a distant
body site
Acute on mild chronic changes
Acute with chronic changes including depressed scars
Subacute Inflammation
• More prolonged, insidious in onset
• Tends to be dryer, red, scaling
• Scale may be significant (suggesting longer
duration)
• Most commonly seen in winter months with
increasing dryness
Subacute
Subacute to chronic with excoriations
Chronic Inflammation
• Tends to be thicker, lichenified (accentuation
of the skin lines, thickening of the skin, may
have thick scale)
• Skin may have a cobblestoned texture
• Results from long standing inflammation and
often chronic scratching
• Not the same as chronic stasis changes
Severe chronic dermatitis with hyperkeratosis
Chronic dermatitis with fibrosis and hyperkeratosis
Chronic SD Changes
• Due to repeated flares and long standing VI
• Most common over the medial lower leg/ankle
• Skin becomes diffusely hyper-pigmented
(hemosiderin deposition), may be thickened or
atrophied with smooth shiny surface
• Scarring and fibrosis may present with
hypo-pigmentation and avascuarization
– Atrophie blanche, inverted champagne bottle
Moderate stasis changes
Chronic stasis changes showing
lipodermatosclerosis changes (inverted champagne
bottle)
Chronic stasis changes with vascular thrombosis
Chronic changes with ulcer
Ulcers
• Primarily occur on medial lower extremity
– Thought to be due to venous reflux of perforating
veins
– May lead to increased fibrin deposition and
increased fibrosis of skin
– Tend to be shallow, painful or minimally painful,
in a setting chronic VI changes, scarring,
atrophie blanche
Ulcers - When To Biopsy
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Not responding to therapy (carefully measure)
Very long standing
Unusual appearance
Unsure of diagnosis
DDx of Ulcers – arterial, neuropathic,
infectious, immunologic, neoplastic,
hematologic, infestations
Typical Clinical Course
• Pts have a history of mild swelling of lower
legs
– Begins in 30’s or 40’s or after child birth, a
surgical procedure, DVT, trauma, weight gain
and others
• Swelling gradually worsens over time
– Is exacerbated by high salt intake, prolonged
standing it is worse at night and better in the
morning
Clinical Course Continued
• Legs get dry especially in winter
• Severe flares with burning itch are more
common (acute on chronic inflammation)
• The color of the lower legs slowly changes
darkening becoming chronically red brown
• Tissue becomes fibrosed or bound down
feeling, areas of scar may appear
• Ulcers begin medially, healing slowly
History
• How severe
– Only in evening, gone in morning, all the time,
drainage, history of ulcer
• Symptoms
– Burn, itch, fatigue, pain
• Prior treatment
– What are they applying (creams, topical
antibiotics, peroxide etc)
History
• Review past medial history
– CHF, DM, neuropathy, DVT, trauma (surgery),
varicosities, arthritis, poor mobility, protein loss
• Medications
– Calcium channel blockers, diuretics- compliance
• How long have they had swelling
– If recent, prolonged sitting or immobilization,
pain in calf, unilateral or bilateral
• Social
– Do they sleep in a flat bed or sitting in a chair
Physical Exam
• General exam
– Pulmonary exam, cardiac exam as indicated
• Pitting edema
– +1 – 4 (subjective but I use 1 ~ slight, 2 ~ ¼ to ½
inch, 3 ~ ½ to ¾ inch, 4 ~> ¾ inch)
– How high does it go? (mid shin, knee, thigh)
– Does it appear to be on the verge of vesiculation
or ulcer?
• Varicosities?
Physical Exam Continued
• Chronic stasis changes
– Pigment changes, atrophie blanche, ulcer scars
• Is it hot, cool, tender
• Evidence of neuropathy (touch toes and sole
or nylon bristle)
• Check pulses (may be hard to feel with
severe edema), capillary refill
• Check both legs
Treatment of SD
• Treat underlying disease
– Venous reflux, CHF
• Treat the underlying cause – blood is pooling
in the TISSUE of the lower leg
– ***The bulk of fluid is in the tissue but the patient
may be intravascularly euvolemic***
• Treat the inflammation
– Reduce the inflammation and repair the skin
Treat ‘Tissue’ Fluid Overload
• Compression and elevation – most important
• Compression hose – knee high is usually OK
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Mild (Class I) 20 - 30 mm Hg
Moderate (Class II) 30 – 40 mm Hg
Severe (Class III) 40 – 50 or even 60 mm Hg
Need to be Mod to be covered by ins
Hard to get on, uncomfortable, hard to manage
especially if arthritis, poor mobility, elderly
After two days
of ACE wrap
Treating ‘Tissue’ Fluid Overload
• Compliance – always an issue
• Tubey grips
– Elastic stocking that comes in 3 sizes, Rx to fold
over in a double layer, pts have to be measured
• OTC Hose
– Light, easier to get on, less uncomfortable ,
come in colors
– Wearing less effective hose is more effective
than not wearing more effective hose
Treating ‘Tissue’ Fluid Overload
• Elevation
– Reversing the venous pooling of blood and aids
in lymphatic drainage
– Feet should be above the buttocks
– Recliners are great (ask where they sleep)
– Elevate bottom 1/3 of mattress with news print or
suit case or foam wedge (under the mattress) to
a height of 3 - 5 inches (‘no leg on a pillow’)
Treating ‘Tissue’ Fluid Overload
• ***Diruetics***
– Decrease the intravascular volume, but most of
the fluid is extravascular, so… though helpful in
fluid overload (CHF) they alone are NOT THE
ANSWER
– Many patients on diuretics have a decreased
intravascular volume and persistent edema
Unna Boot
• A zinc oxide impregnated gauze, covered
with cotton cling and then a double layer of
coban
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Applied in the office and left on 3 – 7 days.
Covers skin with a moist and soothing dressing
Zinc is a cofactor in wound healing
Supplies compression
Takes away compliance as an issue
Unna Boot
• How to apply
– Best to apply after leg has been wrapped as to
minimize edema (seldom done)
– Zinc gauze is wrapped from the foot to above the
calf and just below the knee
– Next a thin layer of cotton cling (+/-)
– Finally a layer of coban (short stretch disposable
wrap), pull to full stretch and then release to 50%
• ? Too tight, have the patient back in 2 – 3 hours
Modified Unna Boot
• Apply clobetasol ointment, followed by cling
and coban
• Good for short duration (2-4 days)
• Decreases inflammation
• I bill as for an Unna boot
The Last Thing on Unna Boots
• http://www.youtube.com/watch?v=cbWkBpgu
2n8&feature=related
– Teach your nurse how to do it well
• Coding for Unna boot
– 29508
– Medicare allowable: $43.16 (Kingston region)
Decreasing Inflammation
(‘Dermatology Part’)
• Topicals
• Class I or II steroid in an ointment base
– Clobetasol (class I) (My ‘go to’)
– Fluocinonide (Lidex) (class II)
– Ointments are less likely to cause contact allergy
• Apply BID for 10 – 14 days
• No other topicals - except Vaseline if needed
Decreasing Inflammation
• Systemic cortisones
– Infrequently used because topicals work well and
side effects
– Used for Id reaction (widely distributed
eczematous reaction)
• Consider infection
– Culture it! – especially for an odiferous or non
healing ulcer
– Don’t ‘jump to antibiotics’
Maintenance Care
• Compression and elevation
– Negotiate a means to maintain minimal edema
– Education, education, education
– Compliance , compliance, compliance – its
always an issue
• Skin care
– Moisturize with Vaseline only
– Limit steroid to 1-2 days per week, BID up to 10
days for flare
Ulcer Treatment
• Consider culture or biopsy if NOT responding
– All biopsies carry a risk of worsening the ulcer
• Wound care
– Avoid debridement, vaseline, non-stick dressing
– Compressed with (ACE wrap, coban, hose)
• Try to avoid adhesives
– Diagram and measure length and widths
– Treat surrounding skin
Patient after 6 months at wound care
After two months of tubey grips 24/7
and vaseline BID
Case I
• 52 YO woman, works as a toll collector, sits
on a stool or stands 8 hours a day
• Swelling in legs worsening over last year,
better in morning
• Legs get red and are now slightly discolored
• Not using moisturizer, no other topicals
• Itch at times
Moderate edema with mild stasis changes
Case I Treatment
• Hose (education)
– Mild to moderate especially for prolonged
standing or sitting (sell it) (OTC for compliance
and esthetics)
• Elevate (education)
– When able, bottom 1/3 of bed… recurring
dividend
• Moisturize (education)
– Cream or vaseline especially in winter
Case II
• 48 YO obese female with history of leg edema
following child birth now with chronic
swelling, stands at auto parts counter 8 hrs
per day
• Worsening, has swelling in morning, pain
• Has not had an ulcer
• Severe redness and itch at times
• Uses OTC anti-itch cream, polysporin
Case II Treatment
• Hose (education)
– Mod compression all day maybe tubey grips HS
• Elevation (education)
– Over lunch, evening, bed (be realistic)
• Topical (education)
– Moisturize daily with Vaseline
– Clobetasol Ung for flares BID up to 10-14 days
Case III
• 72 YO male, DMII and arthritis
• Many year history of swelling, worse now,
pain, oozing at times, R > L legs
• Ulcer 3 years ago, healed at wound center
• Wears old hose sometimes – don’t help
• Using peroxide to dry up the legs
• Sleeps in a bed
Note cut socks
Case III Treatment
• New hose (education)
– Moderate (rubber gloves, cuff), OTC, tubey grips
• Elevation (education)
– Recliner, bed (dividend), whenever sitting
• Topicals
– Bathe regularly, clobetasol ointment BID for 2
weeks then vaseline daily
• FU – 2 weeks (education, compliance)
Case IV
• 72 YO morbidly obese female with long
standing swelling and scaling, recently worse,
history of CHF takes Lasix 20 mg BID (+/-),
arthritis
• Leg is oozing fluid, non painful ulcer
• No hose
• Lives alone and sleeps sitting in a chair
• No topicals
Case IV Treatment
• Hose (education)
– Clobetasol ung and Ace wrap today, to leave on
over night and Una Boot in the AM
• Elevation (education)
– Recliner, bottom 1/3 of bed (be persistant)
• Topicals to be addressed as per case III
• Medical
– ? Change Lasix to 40mg QD, when?, ? Echo etc
• FU 4 – 7 days, ? Visting or office nurse visit
Thank you !
Questions?