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Stasis Dermatitis: Pathophysiology, Evaluation, and Management

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Abstract

Stasis dermatitis commonly occurs in older age. It is caused by venous hypertension resulting from retrograde flow due to incompetent venous valves, valve destruction, or obstruction of the venous system. Further tissue changes arise from an inflammatory process mediated by metalloproteinases, which are up-regulated by ferric ion from extravasated red blood cells. Stasis dermatitis presents initially as poorly demarcated erythematous plaques of the lower legs bilaterally, classically involving the medial malleolus. It is one of the spectrum of cutaneous findings that may result from chronic venous insufficiency. Its mimics include cellulitis, contact dermatitis, and pigmented purpuric dermatoses. Duplex ultrasound is useful in demonstrating venous reflux when the clinical diagnosis of stasis dermatitis is inadequate. Conservative treatment involves the use of compression therapy directed at improving ambulatory venous pressure. Interventional therapy currently includes minimally invasive techniques such as endovenous thermal ablation and ultrasound-guided foam sclerotherapy, which have supplanted the use of open surgical techniques.

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References

  1. Maffei FHA, Magaldi C, Pinho SZ, Lastoria S, Pinho W, Yoshida WB, et al. Varicose veins and chronic venous insufficiency in Brazil: prevalence among 1755 inhabitants of a country town. Int J Epidemiol. 1986;15:210–7.

    Article  CAS  PubMed  Google Scholar 

  2. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol. 2005;15(3):175–84.

    Article  PubMed  Google Scholar 

  3. Yalçin B, Tamer E, Toy GG, Oztaş P, Hayran M, Alli N. The prevalence of skin diseases in the elderly: analysis of 4099 geriatric patients. Int J Dermatol. 2006;45(6):672–6.

    Article  PubMed  Google Scholar 

  4. Weismann K, Krakauer R, Wanscher B. Prevalence of skin diseases in old age. Acta Derm Venereol. 1980;60(4):352–3.

    CAS  PubMed  Google Scholar 

  5. Beauregard S, Gilchrest BA. A survey of skin problems and skin care regimens in the elderly. Arch Dermatol. 1987;123(12):1638–43.

    Article  CAS  PubMed  Google Scholar 

  6. White JV, Ryjewski C. Chronic venous insufficiency. Perspect Vase Surg Endovasc Ther. 2005;17(4):319–27.

    Article  Google Scholar 

  7. McGuckin MR, Waterman JB, Brooks J, Cherry G, Porten L, Hurley S, et al. Validation of venous leg ulcer guidelines in the United States and United Kingdom. Am J Surg. 2002;183(2):132–7.

    Article  PubMed  Google Scholar 

  8. Kistner RL, Eklof B, Masuda EM. Diagnosis of chronic venous disease of the lower extremities: the “CEAP” classification. Mayo Clin Proc. 1996;71(4):338–45.

    Article  CAS  PubMed  Google Scholar 

  9. Bergan JJ, Schmid-Schönbein GW, Smith PDC, Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med. 2006;355(5):488–98.

    Article  CAS  PubMed  Google Scholar 

  10. Labropoulos N. Hemodynamic changes according to the CEAP classification. Phlebolymphology. 2003;40:130–6.

    Google Scholar 

  11. Payne SP, London NJ, Newland CJ, Thrush AJ, Barrie WW, Bell PR. Ambulatory venous pressure: correlation with skin condition and role in identifying surgically correctible disease. Eur J Vasc Endovasc Surg. 1996;11:195–200.

    Article  CAS  PubMed  Google Scholar 

  12. Sippel K, Mayer D, Ballmer B, Dragieva G, Läuchli S, French LE, et al. Evidence that venous hypertension causes stasis dermatitis. Phlebology. 2011;26(8):361–5.

    Article  CAS  PubMed  Google Scholar 

  13. Burnand KG, Whimster I, Naidoo A, Browse NL. Pericapillary fibrin in the ulcer-bearing skin of the leg: the cause of lipodermatosclerosis and venous ulceration. Br Med J (Clin Res Ed). 1982;285:1071–2.

    Article  CAS  Google Scholar 

  14. Moyses C, Cederholm-Williams SA, Michel CC. Haemoconcentration and accumulation of white cells in the feet during venous stasis. Int J Microcirc Clin Exp. 1987;5:311–20.

    CAS  PubMed  Google Scholar 

  15. Thomas PR, Nash GB, Dormandy JA. White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin. Br Med J (Clin Res Ed). 1988;296:1693–5.

    Article  CAS  Google Scholar 

  16. Wilkinson LS, Bunker C, Edwards JC, Scurr JH, Smith PD. Leukocytes: their role in the etiopathogenesis of skin damage in venous disease. J Vasc Surg. 1993;17:669–75.

    Article  CAS  PubMed  Google Scholar 

  17. Jacob MP, Badier-Commander C, Fontaine V, Benazzoug Y, Feldman L, Michel JB. Extracellular matrix remodeling in the vascular wall. Pathol Biol (Paris). 2001;49(4):326–32.

    Article  CAS  Google Scholar 

  18. Herouy Y, Mellios P, Bandemir E, Dichmann S, Nockowski P, Schöpf E, et al. Inflammation in stasis dermatitis upregulates MMP-1, MMP-2 and MMP-13 expression. J Dermatol Sci. 2001;25(3):198–205.

    Article  CAS  PubMed  Google Scholar 

  19. Wenk J, Foitzik A, Achterberg V. Selective pick-up of increased iron by deferoxamine-coupled cellulose abrogates the iron-driven induction of matrix-degrading metalloproteinase-1 and lipid peroxidation in human dermal fibroblasts in vitro:a new dressing concept. J Invest Dermatol. 2001;116:833–9.

    Article  CAS  PubMed  Google Scholar 

  20. Ruckley CV, Evans CJ, Allan PL, Lee AJ, Fowkes FGR. Chronic venous insufficiency: clinical and duplex correlations. The Edinburgh Vein Study of venous disorders in the general population. J Vasc Surg. 2002;36:520–5.

    Article  PubMed  Google Scholar 

  21. Collins L, Seraj S. Diagnosis and treatment of venous ulcers. Am Fam Physician. 2010;15;81(8):989–96.

  22. Palmer B, Xia Y, Cho S, Lewis FS. Acroangiodermatitis secondary to chronic venous insufficiency. Cutis. 2010;86(5):239–40.

    PubMed  Google Scholar 

  23. Lugović L, Pusić J, Situm M, Buljan M, Bulat V, Sebetić K, et al. Acroangiodermatitis (pseudo-Kaposi sarcoma): three case reports. Acta Dermatovenerol Croat. 2007;15(3):152–7.

    PubMed  Google Scholar 

  24. Yi JU, Lee CW. Acroangiodermatitis. A clinical variant of stasis dermatitis. Int J Dermatol. 1990;29(7):515–6.

    Article  CAS  PubMed  Google Scholar 

  25. Hepburn MJ, Dooley DP, Ellis MW. Alternative diagnoses that often mimic cellulitis. Am Fam Physician. 2003;67:2471.

    PubMed  Google Scholar 

  26. David CV, Chira S, Eells SJ, Ladrigan M, Papier A, Miller LG, et al. Diagnostic accuracy in patients admitted to hospitals with cellulitis. Dermatol Online J. 2011;17(3):1.

    PubMed  Google Scholar 

  27. Arakaki RY, Strazzula L, Woo E, Kroshinsky D. The impact of dermatology consultation on diagnostic accuracy and antibiotic use among patients with suspected cellulitis seen at outpatient internal medicine offices: a randomized clinical trial. JAMA Dermatol. 2014;150(10):1056–61.

    Article  PubMed  Google Scholar 

  28. Bailey E, Kroshinsky D. Cellulitis: diagnosis and management. Dermatol Ther. 2011;24:229–39.

    Article  PubMed  Google Scholar 

  29. Stevens DL, Bisno AL, Chambers HF, Everett ED, Dellinger P, Goldstein EJ, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373–406.

    Article  PubMed  Google Scholar 

  30. Keller EC, Tomecki KJ, Alraies MC. Distinguishing cellulitis from its mimics. Cleve Clin J Med. 2012;79(8):547–52.

    Article  PubMed  Google Scholar 

  31. Barron GS, Jacob SE, Kirsner RS. Dermatologic complications of chronic venous disease: medical management and beyond. Ann Vasc Surg. 2007;21:652–62.

    Article  PubMed  Google Scholar 

  32. Machet L, Couhé C, Perrinaud A, Hoarau C, Lorette G, Vaillant L. A high prevalence of sensitization still persists in leg ulcer patients: a retrospective series of 106 patients tested between 2001 and 2002 and a meta-analysis of 1975–2003 data. Br J Dermatol. 2004;150(5):929–35.

    Article  CAS  PubMed  Google Scholar 

  33. Sardana K, Sarkar R, Sehgal VN. Pigmented purpuric dermatoses: an overview. Int J Dermatol. 2004;43(7):482–8.

    Article  PubMed  Google Scholar 

  34. Ratnam KV, Su WPD, Peters MS. Purpura simplex (inflammatory purpura without vasculitis). A clinicopathologic study of 174 cases. J Am Acad Dermatol. 1991;25:642–7.

    Article  CAS  PubMed  Google Scholar 

  35. Kelly RI, Opie J, Nixon R. Golfer’s vasculitis. Australas J Dermatol. 2005;46(1):11–4.

    Article  PubMed  Google Scholar 

  36. Weedon D. Stasis dermatitis. In: Weedon D, editor. Weedon’s skin pathology, 3rd ed. Amsterdam: Churchill Livingstone, Elsevier; 2010.

  37. Rapini RP. Stasis dermatitis. In: Rapini RP, editor. Practical dermatopathology. 2nd ed. Amsterdam: Elsevier; 2012.

    Google Scholar 

  38. Kim D, Kang WH. Role of dermal melanocytes in cutaneous pigmentation of stasis dermatitis: a histopathological study of 20 cases. J Korean Med Sci. 2002;17(5):648–54.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Obermayer A, Garzon K. Identifying the source of superficial reflux in venous leg ulcers using duplex ultrasound. J Vasc Surg. 2010;52(5):1255–61.

    Article  PubMed  Google Scholar 

  40. Lurie F, Comerota A, Eklof B, Kistner RL, Labropoulos N, Lohr J, et al. Multicenter assessment of venous reflux by duplex ultrasound. J Vasc Surg. 2012;55(2):437–45.

    Article  PubMed  Google Scholar 

  41. Nicolaides AN, Cardiovascular Disease Educational and Research Trust; European Society of Vascular Surgery; The International Angiology Scientific Activity Congress Organization; International Union of Angiology; Union Internationale de Phlebologie at the Abbaye des Vaux de Cernay. Investigation of chronic venous insufficiency: a consensus statement (France, March 5–9, 1997). Circulation. 2000;102(20):E126–63.

    Article  CAS  PubMed  Google Scholar 

  42. Malgor RD, Labropoulos N. Diagnosis of venous disease with duplex ultrasound. Phlebology. 2013;28(Suppl 1):158–61.

    Article  PubMed  Google Scholar 

  43. Zygmunt JA. Duplex ultrasound for chronic venous insufficiency. J Invasive Cardiol. 2014;26(11):E149–55.

    PubMed  Google Scholar 

  44. Neglen P, Raju S. A comparison between descending phlebography and duplex Doppler investigation in the evaluation of reflux in chronic venous insufficiency: a challenge to phlebography as the “gold standard”. J Vasc Surg. 1992;16(5):687–93.

    Article  CAS  PubMed  Google Scholar 

  45. Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2001;(2):CD000265.

  46. Al Shammeri O, AlHamdan N, Al-Hothaly B. Chronic venous insufficiency: prevalence and effect of compression stockings. Int J Health Sci (Qassim). 2014;8(3):231–6.

    Article  PubMed Central  Google Scholar 

  47. Stolk R, Wegen van der-Franken CP, Neumann HA. A method for measuring the dynamic behavior of medical compression hosiery during walking. Dermatol Surg. 2004;30(5):729–36.

    CAS  PubMed  Google Scholar 

  48. van der Wegen-Franken CP, Mulder P, Tank B, Neumann HA. Variation in the dynamic stiffness index of different types of medical elastic compression stockings. Phlebology. 2008;23(2):77–84.

    Article  PubMed  Google Scholar 

  49. Neumann HA. Compression therapy with medical elastic stockings for venous diseases. Dermatol Surg. 1998;24(7):765–70.

    Article  CAS  PubMed  Google Scholar 

  50. Raju S, Hollis K, Neglen P. Use of compression stockings in chronic venous disease: patient compliance and efficacy. Ann Vasc Surg. 2007;21(6):790–5.

    Article  PubMed  Google Scholar 

  51. Suehiro K, Morikage N, Yamashita O, Harada T, Ueda K, Samura M, et al. Adherence to and efficacy of different compression methods for treating chronic venous insufficiency in the elderly. Phlebology. 2016;31(10):723-28.

  52. Keller A, Müller ML, Calow T, Kern IK, Schumann H. Bandage pressure measurement and training: simple interventions to improve efficacy in compression bandaging. Int Wound J. 2009;6(5):324–30.

    Article  PubMed  Google Scholar 

  53. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130(4):333–46.

    Article  PubMed  Google Scholar 

  54. Sippel K, Seifert B, Hafner J. Donning devices (foot slips and frames) enable elderly people with severe chronic venous insufficiency to put on compression stockings. Eur J Vasc Endovasc Surg. 2015;49(2):221–9.

    Article  CAS  PubMed  Google Scholar 

  55. Ramelet AA. Compression therapy. Dermatol Surg. 2002;28(1):6–10.

    CAS  PubMed  Google Scholar 

  56. Callam MJ, Ruckley CV, Dale JJ, Harper DR. Hazards of compression treatment of the leg: an estimate from Scottish surgeons. Br Med J (Clin Res Ed). 1987;295(6610):1382.

    Article  CAS  Google Scholar 

  57. Nicolaides AN, Allegra C, Bergan J. Management of chronic venous disorders of the lower limbs: guidelines according to scientific evidence. Int Angiol. 2008;27(1):1–59.

    CAS  PubMed  Google Scholar 

  58. Martinez MJ, Bonfill X, Moreno RM, Vargas E, Capellà D. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev. 2005;(3):CD003229.

  59. Ramelet AA, Boisseau MR, Allegra C, Nicolaides A, Jaeger K, Carpentier P, et al. Veno-active drugs in the management of chronic venous disease. An international consensus statement: current medical position, prospective views and final resolution. Clin Hemorheol Microcirc. 2005;33(4):309–19.

    CAS  PubMed  Google Scholar 

  60. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012;(11):CD003230.

  61. Allaert FA. Meta-analysis of the impact of the principal venoactive drugs agents on malleolar venous edema. Int Angiol. 2012;31(4):310–5.

    CAS  PubMed  Google Scholar 

  62. Bergan JJ. Chronic venous insufficiency and the therapeutic effects of Daflon 500 mg. Angiology. 2005;56(Suppl 1):S21–4.

    Article  PubMed  Google Scholar 

  63. Aziz Z, Tang WL, Chong NJ, Tho LY. A systematic review of the efficacy and tolerability of hydroxyethylrutosides for improvement of the signs and symptoms of chronic venous insufficiency. J Clin Pharm Ther. 2015;40(2):177–85.

    Article  CAS  PubMed  Google Scholar 

  64. Gloviczki P, Comerota AJ, Dalsing MC, Eklof BG, Gillespie DL, Gloviczki ML, et al. The care of patients with varicose veins and associated chronic venous diseases: clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg. 2011;53(5 Suppl):2S–48S.

    Article  PubMed  Google Scholar 

  65. Hamdan A. Management of varicose veins and venous insufficiency. JAMA. 2012;308(24):2612–21.

    Article  CAS  PubMed  Google Scholar 

  66. Carroll C, Hummel S, Leaviss J, Ren S, Stevens JW, Cantrell A, et al. Systematic review, network meta-analysis and exploratory cost-effectiveness model of randomized trials of minimally invasive techniques versus surgery for varicose veins. Br J Surg. 2014;101(9):1040–52.

    Article  CAS  PubMed  Google Scholar 

  67. Brittenden J, Cotton SC, Elders A, Tassie E, Scotland G, Ramsay CR, et al. Clinical effectiveness and cost-effectiveness of foam sclerotherapy, endovenous laser ablation and surgery for varicose veins: results from the Comparison of Laser, Surgery and foam Sclerotherapy (CLASS) randomised controlled trial. Health Technol Assess. 2015;19(27):1–342.

    Article  PubMed  PubMed Central  Google Scholar 

  68. Tassie E, Scotland G, Brittenden J, Cotton SC, Elders A, Campbell MK, et al. Cost-effectiveness of ultrasound-guided foam sclerotherapy, endovenous laser ablation or surgery as treatment for primary varicose veins from the randomized CLASS trial. Br J Surg. 2014;101(12):1532–40.

    Article  CAS  PubMed  Google Scholar 

  69. Rasmussen LH, Lawaetz M, Bjoern L, Vennits B, Blemings A, Eklof B. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg. 2011;98(8):1079–87.

    Article  CAS  PubMed  Google Scholar 

  70. Davies HO, Popplewell M, Darvall K, Bate G, Bradbury AW. A review of randomised controlled trials comparing ultrasound-guided foam sclerotherapy with endothermal ablation for the treatment of great saphenous varicose veins. Phlebology. 2016;31(4):234–40.

    Article  PubMed  Google Scholar 

  71. Chapman-Smith P, Browne A. Prospective five-year study of ultrasound-guided foam sclerotherapy in the treatment of great saphenous vein reflux. Phlebology. 2009;24(4):183–8.

    Article  CAS  PubMed  Google Scholar 

  72. Barrett JM, Allen B, Ockelford A, Goldman MP. Microfoam ultrasound-guided sclerotherapy of varicose veins in 100 legs. Dermatol Surg. 2004;30(1):6–12.

    PubMed  Google Scholar 

  73. Almeida JI, Raines JK. Ambulatory phlebectomy in the office. Perspect Vasc Surg Endovasc Ther. 2008;20(4):348–55.

    Article  PubMed  Google Scholar 

  74. Weiss SC, Nguyen J, Chon S, Kimball AB. A randomized controlled clinical trial assessing the effect of betamethasone valerate 0.12% foam on the short-term treatment of stasis dermatitis. J Drugs Dermatol. 2005;4(3):339–45.

  75. Tafazzoli A, Rostan EF, Goldman MP. Q-switched ruby laser treatment for postsclerotherapy hyperpigmentation. Dermatol Surg. 2000;26(7):653–6.

    Article  CAS  PubMed  Google Scholar 

  76. Pimentel CL, Rodriguez-Salido MJ. Pigmentation due to stasis dermatitis treated successfully with a noncoherent intense pulsed light source. Dermatol Surg. 2008;34(7):950–1.

    CAS  PubMed  Google Scholar 

  77. Gan SD, Orringer JS. Hemosiderin hyperpigmentation: successful treatment with Q-switched 755-nm laser therapy. Dermatol Surg. 2015;41(12):1443–4.

    Article  CAS  PubMed  Google Scholar 

  78. Mlosek RK, Woźniak W, Malinowska S, Migda B, Serafin-Król M, Miłek T. The removal of post-sclerotherapy pigmentation following sclerotherapy alone or in combination with crossectomy. Eur J Vasc Endovasc Surg. 2012;43(1):100–5.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. University of Texas McGovern Medical School at Houston, Houston, TX, USA

    Swaminathan Sundaresan

  2. Departments of Dermatology and Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA

    Michael R. Migden

  3. Department of Dermatology, University of Texas McGovern Medical School at Houston, 6655 Travis St, Ste 980, Houston, TX, 77030, USA

    Sirunya Silapunt

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  1. Swaminathan Sundaresan
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Sundaresan, S., Migden, M.R. & Silapunt, S. Stasis Dermatitis: Pathophysiology, Evaluation, and Management. Am J Clin Dermatol 18, 383–390 (2017). https://doi.org/10.1007/s40257-016-0250-0

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