Varicose eczema is a local inflammatory lesion of the skin of the lower extremities that occurs in people with chronic venous insufficiency. Dermatitis with varicose veins is represented by itchy eczematous foci on the shins in the form of wet plaques, vesicles, crusts. Inflammatory changes are combined with varicose veins, hyperpigmentation, lipodermatosclerosis and trophic ulcers. The diagnosis is established according to clinical data, in difficult cases, ultrasound dopplerography of veins, skin biopsy with histological analysis is performed. Treatment involves drug correction (systemic, local), compression therapy, invasive interventions.
Varicose eczema (congestive, gravitational dermatitis, varicose dermatitis) is characteristic of 2.7-10% of patients with venous insufficiency of the lower extremities. It is usually encountered by people after the age of 50 – in this group, the prevalence of pathology is 6-7%, but increases with each decade. In the elderly and senile age, changes in the skin occur already in 20-22% of cases. Gender and geographical differences are ambiguous: having a relative preponderance among European women, congestive eczema shows a significant prevalence among men of Indian nationality.
Chronic venous insufficiency is recognized as the main cause of skin pathology in gravitational dermatitis. It causes a complex of disorders that provoke an inflammatory eczematous process in a number of patients. The following factors influence the development of the disease:
- Trophic ulcers. Secondary periulcerous dermatitis occurs around ulcerative defects. Its development is promoted by hypersensitivity to topical drugs, maceration of the skin when applying ointment dressings.
- Injuries and surgical interventions. In conditions of venous stagnation, damage to the skin during injuries and surgical interventions worsens the protective properties of the epithelium, accelerates the development of the inflammatory process, deepens trophic disorders.
- Sensitization to microbes. Varicose eczema is called a type of microbial, indicating an etiological connection with the allergization of the body to antigens of resident and transient flora (Staphylococcus aureus, beta-hemolytic streptococcus, yeast-like fungi).
- Deep thrombosis and thrombophlebitis. The frequency of dermatitis increases when a history of cases of deep thrombosis and thrombophlebitis is indicated. The diseases are accompanied by valvular destruction, which supports venous hypertension even after recanalization of stenosis.
Unmodified risk factors for dermatitis include female gender, hereditary predisposition (association with HLA-B22HLA-Cw1 antigens). Obesity has an adverse effect, as well as lifestyle features: physical inactivity, work associated with prolonged standing.
The mechanism of development of varicose eczema has been studied quite well. Dermatological disorders are largely explained by endothelial dysfunction and inflammation. The most important role is assigned to venous hypertension with increased hydrostatic pressure, increased capillary permeability, extravasation of erythrocytes and plasma proteins. This provokes edema of perivascular tissues, the deposition of hemosiderin in them, the formation of hyaline cuffs. This is how microangiopathy is formed, which disrupts the diffusion of oxygen and nutrients.
Slowing of blood flow is accompanied by leukocyte adhesion, activation of neutrophils and macrophages. Penetrating into tissues, cellular elements release proinflammatory mediators, proteases, reactive oxygen species, initiating pericapillary inflammation. Iron ions from hemosiderin deposits enhance lipid peroxidation, activate matrix metalloproteinases, creating a kind of vicious circle. Accumulation of platelets in the microcirculatory bed with a violation of the balance of coagulation and fibrinolysis triggers the process of local thrombosis.
The subsequent imbalance in the capillary network provokes fibrosis and tissue remodeling, lipodermatosclerosis. There is a dysfunction of lymphatic vessels, stellate sclerotic zones are formed, depleted by capillaries (white atrophy). These same processes later initiate the formation of ulcerative defects. Skin inflammation is characterized by epidermal dysfunction (violation of barrier properties, hyperproliferation, desquamation), which leads to the development of asteotic (dry) eczema and the attachment of microbial flora.
Classification of varicose eczema
Congestive dermatitis is included in the structure of chronic venous diseases according to the CEAP international classification, which takes into account clinical, etiological, anatomical and pathophysiological criteria. Pathology belongs to group C4 (skin changes), consisting of two subgroups – C4a (hyperpigmentation, eczema) and C4b (white atrophy, dermatosclerosis). In practical phlebology , there are several forms of varicose eczema:
- Acute and chronic. According to the clinical stage, in many cases the pathology proceeds acutely, with detailed symptoms. Abortive options are less common. Passing into the chronic stage, the process is characterized by periodic exacerbations and remissions.
- Primary and secondary. Arising on externally unchanged skin or with signs of hemosiderosis (but without trophic ulcers), eczema is considered primary. Secondary dermatitis is called periulcerous, forming around areas of active ulceration.
- Uncomplicated and complicated. A smooth course of pathology is observed in the early stages of the inflammatory process. Complications are caused by the progression of stagnant and inflammatory phenomena with untimely and inadequate therapy.
In addition to the above, the degree of severity of skin manifestations (localized, widespread) is taken into account. The presented classification contributes to a clearer formulation of the clinical diagnosis, and, as a result, the choice of the correct therapeutic tactics.
Symptoms of varicose eczema
Signs of the disease usually occur on the skin of the inner surface of the lower third of the lower leg. Sometimes the process extends to the lateral areas, the ankle joint, the foot. As a symptom of venous insufficiency, mild edema appears first, more pronounced in the evening. Stagnant phenomena are accompanied by a mottled brown pigmentation that occurs due to the deposition of hemosiderin. The skin looks dry and scaly, itching appears.
Although dermatitis is diffuse, in some cases it is manifested by isolated plaques. Intense itching leads to numerous combs, followed by wetness and crusts. Rashes are polymorphic in nature, when various elements with clear boundaries, serous or serous-hemorrhagic exudation are concentrated in one area. Erythematous foci are covered with lamellar scale-crusts, microvesicles are formed on the periphery.
Acute forms are accompanied by itchy plaques with a pronounced exudative component and bubbles. Sometimes impetiginous crusts and pustules appear against this background due to bacterial superinfection. Inflammation can pass to the subcutaneous tissue, penetrating subfascially and accompanied by pain. Sensitization of tissues to the components of local therapy in many patients triggers secondary dissemination: spots acquire a symmetrical character, especially on the anterior surface of the opposite shin, thighs. Such eczema can cover the upper extremities, trunk, face.
Chronic varicose eczema is characterized by pronounced lichenification. Red cyanotic plaques appear in weakly vascularized areas. Being covered with coarse scales, the skin thickens and becomes uneven. Gradually, there is a compaction of subcutaneous tissue and deep fascia – a rounded cuff squeezing the distal part of the lower leg makes it look like an inverted bottle of champagne. The skin is intensely pigmented with white star-shaped scars.
Delayed or inadequate treatment of congestive eczema contributes to the appearance of long-term non-healing trophic ulcers. Violation of the integrity of the epidermal barrier contributes to the secondary microbial contamination of eczematous foci with the development of superficial (impetigo) or deep (cellulite, erysipelas) superinfection. The direct consequences of varicose eczema include lipodermatosclerosis (a chronic variant of panniculitis), lymphedema, white atrophy. Autosensitization and contact allergic dermatitis are observed in 60% of patients. Pathology increases the risk of keratoacanthoma and squamous cell carcinoma, worsens the quality of life, leading to psychological problems and depression.
The disease is detected on the basis of a clinical picture with fairly characteristic skin symptoms that occur against the background of venous insufficiency phenomena. With atypical variants of varicose eczema, additional methods can be used in the diagnosis:
- Ultrasound dopplerography of the veins of the lower extremities. It is used to assess hemodynamics or diagnose deep thrombosis in the presence of skin changes without obvious failure of outflow. To detect reflux, ultrasound angioscanning is performed in the horizontal and vertical position of the patient. In case of trophic disorders, arterial hemodynamics is examined in parallel.
- Histological analysis of skin biopsies. It shows signs of an inflammatory process with the phenomena of acanthosis and hyperkeratosis of the epidermis, deposition of hemosiderin in the dermis. Microangiopathy is indicated by the expansion and elongation of capillaries, an increase in the amount of type IV collagen in the basement membrane, and the formation of fibrin cuffs.
Certain information is provided by dermatoscopy, which detects group or glomerular vessels distributed throughout the focus. If the symptoms worsen, despite active therapy, then allergic tests are prescribed to identify possible sensitization. Assessment of the course of the wound process with concomitant ulcers is carried out using microscopic and cultural analysis of smears.
Sometimes a phlebologist surgeon may have difficulties in the differential diagnosis of a disease with true or dry eczema, superficial dermatomycosis, allergic contact dermatitis. It is necessary to exclude other diseases – B-cell lymphoma, Kaposi’s sarcoma. Related specialists (dermatologist, oncologist) and the results of additional studies help in this.
Treatment of varicose eczema
Therapeutic correction of varicose eczema involves an impact on the primary process (chronic venous disease) and skin manifestations. Patients are shown a complex treatment consisting of several aspects:
- Drug therapy. Systemic treatment is carried out with venotonics, antibiotics (in case of secondary infection), corticosteroids (with prolonged course and autosensitization). Local treatment consists in cleaning the foci, applying wet-drying bandages with antiseptics. Topical glucocorticoids (in the form of cream), calcineurin inhibitors are effective for itching.
- Elastic compression. With severe edema, elastic bandages of short extensibility are used. In the future, the use of knitted products (socks, stockings, tights) with a nominal pressure of 20-30 mmHg is shown. But with concomitant arterial insufficiency, compression therapy is contraindicated.
- Invasive methods. The presence of ulcerative lesions is an indication for early surgical treatment. Endovascular techniques (sclerotherapy, laser coagulation, radiofrequency ablation) or phlebectomy of surface areas are used. Delayed correction is performed after the elimination of dermatological manifestations.
To improve venous outflow, it is recommended to lift your legs during sleep 15 cm above the level of the heart, perform exercises of therapeutic gymnastics. The effectiveness of phototherapy has been noted in the elimination of stagnant pigmentation. Special attention is paid to foot skin care – washing with soft products, moisturizing with emollients.
Prognosis and prevention
The prognosis is determined by the cause of varicose eczema and its course. Usually the disease takes a chronic form and is difficult to cure. But the delay with active correction can cause complications and concomitant disorders, among which there are quite serious conditions. General preventive measures include normalization of body weight, maintaining physical activity, wearing comfortable shoes and clothes. Secondary prevention involves taking venotonics and elastic compression.