Venous eczema (also called stasis dermatitis or varicose eczema) is itchy, red or darkened, dry and flaky skin on the lower leg, usually just above the ankle. It looks much like ordinary eczema, but the cause is different: it is a sign that the veins in the leg are not working properly. Dr Blignaut describes it to patients as an SOS from the skin.
Creams can settle the skin, but the eczema tends to keep coming back while the underlying vein problem is untreated.
What does venous eczema look like?
- itchy, dry, scaly or flaky skin, most often on the inner side of the lower leg and ankle;
- redness, which can look purple or dark brown on darker skin;
- weeping, crusting or small cracks in the skin when it flares;
- brown staining of the skin around the ankle;
- ankle swelling that is worse at the end of the day;
- often, but not always, visible varicose veins or a fan of small veins around the ankle.
It can affect one leg or both, and it can occur whether or not you have eczema anywhere else.
Why does it happen?
The leg veins have one-way valves that keep blood moving up towards the heart. When these valves leak (venous reflux), blood falls back down the leg. The pressure in the lower-leg veins stays high when you stand, and does not drop properly when you walk.
That raised pressure pushes fluid, proteins and red blood cells out of the small vessels into the skin. The iron from the red blood cells stains the skin brown and, together with white blood cells drawn into the skin, sets off inflammation. The result is itchy, inflamed, fragile skin1.
Less often, the cause is a vein narrowed or blocked by an old clot (after a DVT), or a calf muscle pump that works poorly because of limited walking, a stiff ankle or excess weight.
Why it matters
Venous eczema is more than a skin problem. In the CEAP classification that doctors use to grade vein disease, it is class C4a: a sign that the vein disease has started to damage the skin2.
Without treatment of the cause, the skin can go on to harden and tighten (lipodermatosclerosis) or develop white, scar-like patches (atrophie blanche). Skin in this state heals poorly, and a small knock or scratch can become a venous leg ulcer. This is the stage to have your veins assessed. Treating the cause, and keeping the skin healthy, lowers the chance of an ulcer forming.
Is it venous eczema, or something else?
Several conditions can look similar:
- Allergy to a cream or dressing. Skin affected by venous eczema is easily irritated, and allergic reactions to creams, ointments, dressings, adhesives and the rubber in some bandages are common. A rash that gets worse after a new cream is started may be an allergy rather than the eczema itself.
- Cellulitis (skin infection). Venous eczema is often in both legs, is itchy rather than very painful, and you feel well. When it affects one leg only it can be harder to tell apart from infection, so have it checked. Cellulitis is usually in one leg, hot, painful and spreading, often with fever.
- Lipodermatosclerosis. A red, tender, hard area above the ankle is often mistaken for a recurring infection.
- A skin patch that does not heal. Rarely, a scaly patch or sore that does not respond to treatment is a skin cancer and needs a biopsy.
- Ordinary (atopic) eczema, psoriasis or a fungal infection. These usually affect other parts of the body as well.
An examination and a duplex ultrasound scan of the leg veins usually settle it. If the rash does not behave like venous eczema, your GP or a dermatologist may need to see it, sometimes for allergy (patch) testing.
How we assess it
At your first visit Dr Blignaut examines your legs and does a duplex ultrasound scan of both legs. The scan shows whether the valves in the superficial veins, the deep veins or the perforator veins (the veins that connect the two) are leaking or blocked, and exactly where. Where indicated, we also measure the ankle-brachial pressure index (ABPI) to check the arteries before recommending compression.
Treatment
1. Settle the skin
- Moisturise every day. A plain, fragrance-free moisturiser or emollient, used generously, reduces itching and flare-ups. Use a soap substitute when you wash.
- Steroid cream for flare-ups. A short course of a prescribed steroid cream or ointment usually settles a flare. Use it as directed and only on the affected skin.
- Take care with paraffin-based moisturisers. They soak into clothing and bedding and make them burn easily. Keep away from open flames and do not smoke while using them.
- Avoid irritants. Avoid perfumed products and creams you have reacted to before. Tell us about any reaction to a cream or dressing.
- Antibiotics only for infection. Antibiotics do not help venous eczema unless the skin is genuinely infected.
2. Reduce the pressure
Raising your legs when you sit, walking regularly and avoiding long periods of standing all help. Compression stockings reduce the pressure in the lower leg and the swelling3. Where indicated, we check the arteries first. Settling the skin first, and moisturising at night rather than just before putting stockings on, makes them easier to wear.
3. Treat the leaking veins
Creams and compression manage the symptoms. Treating the leaking vein addresses the cause. When the scan shows reflux, the faulty vein can be closed under local anaesthetic in our rooms, with no hospital admission, using radiofrequency ablation, often combined with ultrasound-guided foam sclerotherapy. Current guidelines recommend treating leaking surface veins in patients with skin changes such as venous eczema3. If the leak or blockage is in the deep veins, compression and skin care remain the main treatment, and some patients are referred for specialised deep-vein treatment.
Because venous eczema is a medical condition, not a cosmetic one, medical schemes usually fund treatment of the leaking vein once the scan confirms reflux and the procedure has been pre-authorised. The first consultation and scan are paid on the day and claimed from your day-to-day benefits. See fees and medical aid.
When to see a doctor sooner
- sudden painful swelling of one calf or leg: this may be a deep vein clot (DVT). See your GP or go to an emergency department the same day; our centres do not treat acute DVT. If you are short of breath or have chest pain, call 10177, or 112 from a mobile phone;
- the skin becomes hot, very painful and red, the redness is spreading, or you have a fever: this may be an infection and needs a doctor the same day;
- a sore or wound appears in the affected skin, or a small injury does not heal within two weeks;
- a varicose vein in the area bleeds. Lie down, raise the leg high and press firmly on the spot. If the bleeding does not stop, call 10177, or 112 from a mobile phone.
Frequently asked questions
Is venous eczema contagious?
No. It is caused by pressure in the veins, not by an infection, and cannot be passed on.
Will steroid cream cure it?
A steroid cream usually settles a flare-up, but it does not change the vein pressure that causes it, so the eczema tends to come back. Treating the leaking vein reduces the chance of it returning.
I don’t have visible varicose veins. Can it still be my veins?
Yes. The leaking vein can lie under the skin where it cannot be seen. A duplex scan shows whether the veins are the cause.
Do I need a referral?
No, unless your medical scheme option requires a GP referral. You can book directly at any of our centres, or start with the free online vein screening.
References
- Sundaresan S, Migden MR, Silapunt S. Stasis dermatitis: pathophysiology, evaluation, and management. Am J Clin Dermatol. 2017;18(3):383–390. PubMed
- Lurie F, Passman M, Meisner M, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020;8(3):342–352. PubMed
- De Maeseneer MG, Kakkos SK, Aherne T, et al. European Society for Vascular Surgery (ESVS) 2022 clinical practice guidelines on the management of chronic venous disease of the lower limbs. Eur J Vasc Endovasc Surg. 2022;63(2):184–267. ESVS guideline
