Identifying Venous Stasis Dermatitis and Ulcers

Venous stasis is a condition that can be painful and debilitating for patients, affecting quality of life.

Chronic venous disease is a common condition in the U.S. And the Society for Vascular Surgery estimates up to 40% of the U.S. population has this condition.

Venous stasis impacts the flow of blood to the heart, and because of this, it can lead to a variety of symptoms, including swelling, pain, skin changes, and even the development of wounds. Let’s explore venous stasis, as well as the implications for wound care and treatment options available for those affected by this condition.

What is venous stasis?

Venous stasis, also known as chronic venous insufficiency, is a condition where blood in the veins is unable to make its way back to the heart. This causes a retrograde flow of blood, which stems from incompetent valves, venous obstruction like a blood clot, or valve destruction from an injury or surgery.

Most often seen in the lower legs, venous stasis can also be caused by the following:

• Obesity
• Pregnancy
• Advancing age
• Prolonged sitting or standing
• Smoking
• Hypertension
• Kidney disease
• Phlebitis
• Lack of exercise

When blood is unable to move through the valves in the venous system normally, the blood collects in the lower legs. This pooling can cause edema, an achy or heaviness in the legs, and varicosities, which can progress into conditions, including venous stasis dermatitis and venous dermatitis ulcers.

Venous stasis dermatitis defined

Venous stasis can develop into a chronic inflammatory skin condition called venous stasis dermatitis. The reflux of venous stasis creates hypertension in the venous system.

This prolonged condition can cause cutaneous changes to the lower legs, where the skin can become thickened, itchy, scaly, and discolored. If repeated scratching of the tissue occurs, a condition called lichenification may develop, where the skin becomes more thickened and leather like. Chronic skin conditions, such as eczema, can also cause this to occur.

Lipodermatosclerosis may also be noted in the lower leg. This is an inflammatory condition where the subcutaneous skin becomes fibrosed and indurated.

With stasis dermatitis, hemosiderin staining can appear on the ankles and lower legs. This happens when the capillaries leak pooled blood into the tissues of the lower leg. The iron in hemoglobin causes a brown or rusty look to the skin. Each of these skin changes are signs of underlying venous insufficiency or venous stasis.

It can be challenging to determine if a patient has color changes due to stasis dermatitis or cellulitis. You can differentiate venous stasis dermatitis from cellulitis by its chronic, usually bilateral presence. Cellulitis is often noted in one leg and is accompanied by other signs of infection, including fever, chills, and bright red skin with increased warmth.

It is not uncommon for patients with chronic stasis dermatitis to also develop cellulitis. This may happen when bacteria are introduced into hardened, dry, cracked, itchy skin. Scratching, or other means of trauma, can easily transmit bacteria into damaged, vulnerable skin.

Treating and preventing dermatitis

Treatment for both venous insufficiency and venous stasis dermatitis is similar. The focus is moving the pooled blood and fluid out of the lower legs and back into the circulatory and lymphatic systems, which can be achieved by using compression. Properly fitted compression stockings are very effective at treatment of mild disease as well as prevention of disease progression.

Obtain ankle and calf measurements prior to the patient ordering their stockings. This is an important part of patient compliance. Ill-fitting stockings are likely to slouch, roll down, or cut in to the patient’s legs. It can be difficult to convince some patients to try compression stockings again if they previously had difficulty with them.

In addition to compression stockings, bilateral lower extremity elevation is effective at edema management. Educating patients on limiting high-sodium, highly processed foods can also help decrease lower extremity swelling. A topical corticosteroid can also help in cases of significant skin irritation.

Patients can take the following actions to effectively manage and prevent the worsening this condition:

• Prophylactic use of compression stockings
• Maintaining a healthy weight
• Increasing physical activity
• Smoking cessation
• Managing comorbidities

Venous stasis ulcer defined

Venous stasis leg ulcers are later stage developments of chronic venous stasis, which is the most common etiology of lower leg wounds, according to research from the National Library of Medicine.

These ulcers are caused by venous reflux and/or venous obstruction. There are cellular and inflammatory changes caused by chronic venous insufficiency, which increase the risk of an ulcer forming, especially if the skin experiences trauma.

These ulcers most often develop on the lower leg between the ankle and knee. They’re often shallow, irregularly shaped, and often experience high draining, which may be challenging to manage.

Oftentimes, venous stasis ulcers are “clean” and will have viable pink/red tissue in the wound bed. Deeper venous ulcers may display necrotic tissue in the wound bed, such as slough.

Risk factors for the development of venous stasis ulcers include:

• Female population
• Sedentary lifestyle
• Obesity
• Advancing age
• Family history of chronic venous insufficiency
• History of thrombosis
• Injury or surgery to the venous system

Treating and preventing ulcers

Once an open wound appears, treatment should include appropriate dressing selection. Primary and secondary dressing selection should accommodate wound bed and peri-wound characteristics.

Along with dressings, treatment should include adequate compression. It is exponentially harder to heal a venous ulcer without adequate compression. With chronic venous insufficiency at this level, diagnostic testing needs to be indicated, especially if wound healing does not progress with the use of compression.

A venous reflux study can be helpful in identifying patients who will benefit from a referral to vascular surgery. Patients with more significant venous disease may require a vascular intervention to achieve wound healing.

Prevention of venous stasis ulcers is like venous stasis and venous stasis dermatitis. The use of prophylactic compression stockings for high-risk patients and those showing signs of early venous disease are key to prevention. It’s also important to address other modifiable risk factors such as smoking, obesity, and sedentary lifestyle along with patient education.

The ins and outs of venous disease can take time, experience, and a little studying to master. But once understood, your patients will benefit from your time and effort to learn more about this common condition.