Varicose eczema (venous stasis dermatitis)

Varicose eczema is itchy, flaky, gradually darkening skin on the lower leg, most often around the ankle. It also goes by venous, stasis or gravitational eczema, and all those names say the same thing: the problem is not in the skin. The skin is suffering because of what is happening beneath it — raised pressure in the leg veins. From which follows the main practical point: the real treatment here is not an ointment but compression and getting the leg up. Ointment damps down the inflammation, and that is needed, but if the pressure in the veins stays the same everything comes back within weeks. People go round the "the cream worked, then the cream stopped working" loop for years precisely because they are treating the consequence.

What it looks like and what it feels like

It usually starts quietly: by evening the lower leg and ankle swell a little, the skin gets dry, and it begins to itch. Over time the picture becomes recognisable:

• dryness and flaking, sometimes crusts and small blisters, and skin that weeps during a flare;
• persistent itching that leads to scratching, and scratches that heal badly;
• a change in colour: on pale skin, redness at first and then rusty-brown patches that stay; on darker skin, areas of deep brown, purple or grey that are harder to make out. The brown tinge does not go when the inflammation settles, because it is iron from blood that has leaked through the vein wall into the skin;
• swelling that goes down overnight and returns by evening — a very typical sign that the origin is venous;
• hardening and tightening of the skin above the ankle, where a band feels firm and constricted while the calf above it looks fuller (this is called lipodermatosclerosis);
• small white scars against the pigmented background;
• often, though not always, visible enlarged veins.

It may affect one leg or both, and it alternates flares with quiet spells. It is not contagious and cannot be caught from anyone.

Why it shows in the skin when the cause is in the veins

Blood in the leg veins travels upwards, against gravity. Two mechanisms help it: valves inside the veins that stop blood falling back, and the calf muscles, which squeeze the veins with every step and push the blood on. When the valves stop closing properly — after a clot, with varicose veins, with age — some of the blood drops back and pools. Pressure in the small vessels of the lower leg rises, fluid and blood cells seep through their walls into the tissue, and the body answers with chronic inflammation. That inflammation is what shows on the outside as eczema.

It is more likely if there are varicose veins, if there has been a deep vein thrombosis, after injury or surgery to the leg, with excess weight, in work that means long spells standing or sitting still, after several pregnancies, with limited mobility and with age. Family history plays a part too.

This page is about the skin of the lower leg. The veins themselves — why they widen, when they should be treated and by what methods nowadays — are covered on the page about varicose veins. One follows from the other, but the questions differ: there the subject is the vessels, here it is what those vessels do to the skin.

Compression and elevation: what makes everything else work

If one thing is worth taking from this page, let it be this. Compression hosiery supports the veins from outside so they cannot stretch, helps the muscles move blood along and clears the swelling — and with the swelling goes what keeps the skin inflamed. Without compression, any ointment buys only a respite.

One important condition: the compression class is chosen by a doctor, who must first check the arterial blood supply to the leg — feeling the pulse at the foot and, usually, measuring the ankle-brachial index by comparing the pressure at the ankle with the pressure at the arm. If the arteries are narrowed, squeezing the leg is dangerous. That is why stockings for this condition are not bought by guesswork at the chemist: both the right class and the right measured size are needed.

Wearing them is more manageable than it sounds: put them on in the morning as soon as you are up, before the leg swells, and take them off at bedtime; keep two pairs so one can be in the wash; if your hands struggle, a stocking frame or rubber gloves help. If a stocking rolls into a band, digs in or rubs, tell your doctor — a rolled band acts like a tourniquet, and that is fixed rather than tolerated. Stretched hosiery no longer compresses, so it is replaced every few months.

Compression works in tandem with movement and elevation. Several times a day it is worth lying down for twenty or thirty minutes with the legs on cushions so the feet are above the level of the heart. Walking here is not general advice about exercise but a specific mechanism: with every step the calf muscle acts as a pump. If you have to stand or sit for long spells, rise onto your toes and flex your ankles every half hour. Losing weight noticeably reduces the load on the veins.

Moisturising: the dull foundation everything rests on

In this condition the skin is dry, and dry skin cracks, itches and lets infection through. So emollients are not used in courses or "when it is bad" but continuously, including during quiet spells. That is the daily treatment, not cosmetics.

How it is done properly. You need plenty of it: cover the whole lower leg, not only the visible patches, at least twice a day and more often if the skin is very dry. Do not rub it in — smooth it on in the direction the hairs grow, because rubbing irritates the skin and can inflame the hair follicles. The best moment is straight after a shower, onto damp skin. Swap soap and shower gel for a wash emollient, since ordinary soap dries the skin. And keep the water warm rather than hot.

Choose the product by how dry the skin is: ointments are the greasiest and hold water best, creams are the middle ground, lotions are lighter but weaker; ointment at night and cream during the day is a workable combination. And one precaution that is rarely mentioned: paraffin-based emollients make fabric flammable — clothing and bedding soaked in them catch light easily — so keep away from naked flames and do not smoke.

Steroid ointment: what it does and what not to expect from it

When the eczema flares — the skin reddens, weeps and itches unbearably — a doctor will prescribe a topical corticosteroid. It damps the inflammation quickly, and it is the right treatment; there is no need to be afraid of it.

It is used to certain rules. The strength is chosen by the doctor: a mild preparation often does nothing on the thick skin of the lower leg, while a potent one should not be used for longer than necessary. Apply it thinly and only to the affected areas, usually once a day, in a short course of one to two weeks, and carry on for a couple of days after the flare has settled so it does not rebound. If an emollient is used the same day, leave about half an hour between the two. Prolonged continuous use of a potent steroid thins the skin, and on the lower leg, where the skin is already fragile, that is particularly unwelcome.

And the key limitation: the ointment removes the inflammation but does not change the pressure in the veins. If everything comes back a month after a good response, that does not mean the ointment is poor or that your body has got used to it. It means the underlying job — compression and swelling — has not been done. See a doctor if the course has finished and there is no improvement: a different strength may be needed, or the diagnosis may be something else entirely.

"I'm allergic to the cream": common, and important

With venous congestion, the skin of the lower leg becomes unusually sensitive to whatever is put on it. Over the years dozens of products get tried, and sooner or later a contact reaction develops: the eczema worsens exactly where the cream was applied, spreads beyond its usual borders, and starts weeping and blistering with a puffy redness. The usual interpretation is that "the disease has got worse", so more medication is added — which is precisely what makes it worse.

The commonest culprits are lanolin, fragrances, preservatives, antibiotics contained in ointments, adhesive components in dressings, and sometimes rubber additives in compression hosiery. Suspect it if the deterioration clearly coincided with starting a new product, or if the eczema traces the shape of the area where it was applied.

This is not sorted out by trying products at the chemist but with a doctor. Patch testing exists for exactly this: a panel of substances is taped to the back for a couple of days and the skin's reaction is read. It gives a definite answer and saves years of guessing. Separately: do not put antiseptics or antibiotic ointments on the leg on your own initiative, because those are the very things that most often set this reaction off. And protect the skin from scratching: keep nails short, use something cool when the itch is bad, and apply emollient. On this skin a scratch turns into an ulcer easily.

When a doctor is needed today

An ordinary eczema flare can wait: book an appointment in the next few days. But this condition has complications where the timescale is not weeks.

See a doctor the same day if the skin on the leg has turned hot, bright red (on darker skin, noticeably darker, shiny and tight) and painful, if the redness is spreading quickly, or if you develop a temperature, shivering and a general feeling of being unwell. That is how erysipelas and cellulitis present — bacterial infection of the skin and the tissue underneath. They are treated with antibiotics, and the sooner that starts the milder the illness. Three things separate them from an eczema flare: pain instead of itching, heat in the skin itself, and feeling ill all over. If things worsen quickly, the temperature is high, or confusion or marked weakness appear, call an ambulance; in Spain, Italy, Portugal, Poland and Ukraine the single number 112 is in use.

A wound on the lower leg that will not heal is a venous leg ulcer, and it is treated with a doctor, not at home. If a graze or a weeping patch has not closed within a couple of weeks, self-treatment stops being harmless. An ulcer is treated with compression bandaging and regular dressings chosen and supervised by a professional, while household antiseptics, hydrogen peroxide and home-made poultices damage the tissue that is trying to heal and waste time. Healing takes weeks to months, and started promptly it goes appreciably faster.

One more reason to be seen the same day: if a whole leg suddenly swells, with pain or tightness in the calf and skin that feels warm. Against a background of venous problems that can be a deep vein thrombosis and needs urgent assessment. And if breathlessness, chest pain or coughing up blood are added to it, call an ambulance straight away.

Online consultation

This is a condition managed over years, and most of the questions it raises are settled by talking rather than examining. Online it is easy to work out why dryness and itching on the lower leg are about the veins rather than an "allergy" or not washing enough; what the brown patches and the hardening above the ankle mean; and how to build a daily routine that can actually be kept to — how often the emollient, when the ointment, when the hosiery.

A doctor can go through the ingredients of the products you already use when a contact reaction is suspected, explain why the arterial supply is checked before compression, talk you through getting stockings on when it simply will not work, and say when it is worth raising treatment of the veins themselves with a vascular surgeon. Photographs in good light, taken over time, are useful to send.

The limits of a remote conversation are simple. Compression cannot be prescribed without examining the leg and feeling the pulse at the foot. An ulcer is not treated from a photograph. And if the skin is hot, bright red and painful, or there is a temperature, what is needed is not a consultation but a doctor in person, today.

This material is for information only and does not replace medical advice.