Chronic erythematous pruritic eruption on the lower legs



A 67-year-old woman presents to the vascular surgeons with varicose veins. She had a
history of venous ulceration in the past, which has now healed and she is being considered
for bilateral varicose vein surgery. At the consultation she complained of a 3-month
history of skin itching and redness, particularly on the right lower leg, and was noted to
have unilateral erythema and was referred to dermatology for an opinion.

This patient has obvious dilated and tortuous veins on both lower legs. Confluent background
dull erythema is seen on the right lower leg, with small inflammatory superficial
erythematous erosions and excoriations (Fig. 6.1). Palpation revealed warm, dry, rough
skin at the affected site.

• What is the diagnosis?
• What treatment would you recommend
for her right leg prior to vein surgery?
• Is this patient suitable for compression
hosiery based on the vascular studies?

This patient has chronic cutaneous changes seen on the right lower leg consistent with
the diagnosis of varicose eczema. This common cutaneous eruption usually has an insidious
onset over many weeks to months in patients with a background of venous incompetence.
The affected skin is pruritic and dry with marked erythema which may be variable
in intensity depending on its chronicity. In the context of venous insufficiency, pitting
oedema may develop owing to poor venous return leaving the skin tight and oedematous.
This results in reduced blood flow to the skin, leading to active dusky erythema and
resultant erosions or even ulceration.
Varicose eczema can be readily distinguished from cellulitis affecting the lower leg.
Varicose eczema usually develops slowly, is frequently bilateral, pruritus is marked, the
skin surface is rough and dry, and there are associated varicose veins. Frequently there is
a background brown discolouration of the affected skin area due to haemosiderin deposition.
Haemosiderin pigment is derived from haemoglobin, which is left behind in the skin
when red blood cells extravasate into the tissue.
Management of the skin requires a combination of topical therapy and if possible compression.
The leg should be washed with aqueous cream or an antiseptic emollient such
as Dermol 500®. A moderately potent topical steroid should be applied to the eczematous
areas and a rich bland emollient. Compression hosiery or two to four layer bandaging is
essential to ‘squeeze’ the fluid out of the legs and allow skin healing. If the ankle/brachial
pressure index (APBI) is above 0.8 then the arteries are sufficiently patent to permit
compression without compromising the arterial blood supply to the lower extremities.