American Journal of Clinical Dermatology

, Volume 18, Issue 3, pp 383–390 | Cite as

Stasis Dermatitis: Pathophysiology, Evaluation, and Management

  • Swaminathan Sundaresan
  • Michael R. Migden
  • Sirunya SilapuntEmail author
Review Article


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.


Venous Insufficiency Compression Stocking Chronic Venous Insufficiency Compression Therapy Chronic Venous Insufficiency 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Compliance with Ethical Standards


No sources of funding were used to conduct this study or prepare this manuscript.

Conflict of interest

Mr. Sundaresan, Dr. Migden, and Dr. Silapunt have no conflicts of interest that are directly relevant to the content of this article.


  1. 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.CrossRefPubMedGoogle Scholar
  2. 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.CrossRefPubMedGoogle Scholar
  3. 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.CrossRefPubMedGoogle Scholar
  4. 4.
    Weismann K, Krakauer R, Wanscher B. Prevalence of skin diseases in old age. Acta Derm Venereol. 1980;60(4):352–3.PubMedGoogle Scholar
  5. 5.
    Beauregard S, Gilchrest BA. A survey of skin problems and skin care regimens in the elderly. Arch Dermatol. 1987;123(12):1638–43.CrossRefPubMedGoogle Scholar
  6. 6.
    White JV, Ryjewski C. Chronic venous insufficiency. Perspect Vase Surg Endovasc Ther. 2005;17(4):319–27.CrossRefGoogle Scholar
  7. 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.CrossRefPubMedGoogle Scholar
  8. 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.CrossRefPubMedGoogle Scholar
  9. 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.CrossRefPubMedGoogle Scholar
  10. 10.
    Labropoulos N. Hemodynamic changes according to the CEAP classification. Phlebolymphology. 2003;40:130–6.Google Scholar
  11. 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.CrossRefPubMedGoogle Scholar
  12. 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.CrossRefPubMedGoogle Scholar
  13. 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.CrossRefGoogle Scholar
  14. 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.PubMedGoogle Scholar
  15. 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.CrossRefGoogle Scholar
  16. 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.CrossRefPubMedGoogle Scholar
  17. 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.CrossRefGoogle Scholar
  18. 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.CrossRefPubMedGoogle Scholar
  19. 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.CrossRefPubMedGoogle Scholar
  20. 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.CrossRefPubMedGoogle Scholar
  21. 21.
    Collins L, Seraj S. Diagnosis and treatment of venous ulcers. Am Fam Physician. 2010;15;81(8):989–96.Google Scholar
  22. 22.
    Palmer B, Xia Y, Cho S, Lewis FS. Acroangiodermatitis secondary to chronic venous insufficiency. Cutis. 2010;86(5):239–40.PubMedGoogle Scholar
  23. 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.PubMedGoogle Scholar
  24. 24.
    Yi JU, Lee CW. Acroangiodermatitis. A clinical variant of stasis dermatitis. Int J Dermatol. 1990;29(7):515–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Hepburn MJ, Dooley DP, Ellis MW. Alternative diagnoses that often mimic cellulitis. Am Fam Physician. 2003;67:2471.PubMedGoogle Scholar
  26. 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.PubMedGoogle Scholar
  27. 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.CrossRefPubMedGoogle Scholar
  28. 28.
    Bailey E, Kroshinsky D. Cellulitis: diagnosis and management. Dermatol Ther. 2011;24:229–39.CrossRefPubMedGoogle Scholar
  29. 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.CrossRefPubMedGoogle Scholar
  30. 30.
    Keller EC, Tomecki KJ, Alraies MC. Distinguishing cellulitis from its mimics. Cleve Clin J Med. 2012;79(8):547–52.CrossRefPubMedGoogle Scholar
  31. 31.
    Barron GS, Jacob SE, Kirsner RS. Dermatologic complications of chronic venous disease: medical management and beyond. Ann Vasc Surg. 2007;21:652–62.CrossRefPubMedGoogle Scholar
  32. 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.CrossRefPubMedGoogle Scholar
  33. 33.
    Sardana K, Sarkar R, Sehgal VN. Pigmented purpuric dermatoses: an overview. Int J Dermatol. 2004;43(7):482–8.CrossRefPubMedGoogle Scholar
  34. 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.CrossRefPubMedGoogle Scholar
  35. 35.
    Kelly RI, Opie J, Nixon R. Golfer’s vasculitis. Australas J Dermatol. 2005;46(1):11–4.CrossRefPubMedGoogle Scholar
  36. 36.
    Weedon D. Stasis dermatitis. In: Weedon D, editor. Weedon’s skin pathology, 3rd ed. Amsterdam: Churchill Livingstone, Elsevier; 2010.Google Scholar
  37. 37.
    Rapini RP. Stasis dermatitis. In: Rapini RP, editor. Practical dermatopathology. 2nd ed. Amsterdam: Elsevier; 2012.Google Scholar
  38. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 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.CrossRefPubMedGoogle Scholar
  40. 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.CrossRefPubMedGoogle Scholar
  41. 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.CrossRefPubMedGoogle Scholar
  42. 42.
    Malgor RD, Labropoulos N. Diagnosis of venous disease with duplex ultrasound. Phlebology. 2013;28(Suppl 1):158–61.CrossRefPubMedGoogle Scholar
  43. 43.
    Zygmunt JA. Duplex ultrasound for chronic venous insufficiency. J Invasive Cardiol. 2014;26(11):E149–55.PubMedGoogle Scholar
  44. 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.CrossRefPubMedGoogle Scholar
  45. 45.
    Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2001;(2):CD000265.Google Scholar
  46. 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.CrossRefPubMedCentralGoogle Scholar
  47. 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.PubMedGoogle Scholar
  48. 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.CrossRefPubMedGoogle Scholar
  49. 49.
    Neumann HA. Compression therapy with medical elastic stockings for venous diseases. Dermatol Surg. 1998;24(7):765–70.CrossRefPubMedGoogle Scholar
  50. 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.CrossRefPubMedGoogle Scholar
  51. 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.Google Scholar
  52. 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.CrossRefPubMedGoogle Scholar
  53. 53.
    Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014;130(4):333–46.CrossRefPubMedGoogle Scholar
  54. 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.CrossRefPubMedGoogle Scholar
  55. 55.
    Ramelet AA. Compression therapy. Dermatol Surg. 2002;28(1):6–10.PubMedGoogle Scholar
  56. 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.CrossRefGoogle Scholar
  57. 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.PubMedGoogle Scholar
  58. 58.
    Martinez MJ, Bonfill X, Moreno RM, Vargas E, Capellà D. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev. 2005;(3):CD003229.Google Scholar
  59. 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.PubMedGoogle Scholar
  60. 60.
    Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012;(11):CD003230.Google Scholar
  61. 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.PubMedGoogle Scholar
  62. 62.
    Bergan JJ. Chronic venous insufficiency and the therapeutic effects of Daflon 500 mg. Angiology. 2005;56(Suppl 1):S21–4.CrossRefPubMedGoogle Scholar
  63. 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.CrossRefPubMedGoogle Scholar
  64. 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.CrossRefPubMedGoogle Scholar
  65. 65.
    Hamdan A. Management of varicose veins and venous insufficiency. JAMA. 2012;308(24):2612–21.CrossRefPubMedGoogle Scholar
  66. 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.CrossRefPubMedGoogle Scholar
  67. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 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.CrossRefPubMedGoogle Scholar
  69. 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.CrossRefPubMedGoogle Scholar
  70. 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.CrossRefPubMedGoogle Scholar
  71. 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.CrossRefPubMedGoogle Scholar
  72. 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.PubMedGoogle Scholar
  73. 73.
    Almeida JI, Raines JK. Ambulatory phlebectomy in the office. Perspect Vasc Surg Endovasc Ther. 2008;20(4):348–55.CrossRefPubMedGoogle Scholar
  74. 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.Google Scholar
  75. 75.
    Tafazzoli A, Rostan EF, Goldman MP. Q-switched ruby laser treatment for postsclerotherapy hyperpigmentation. Dermatol Surg. 2000;26(7):653–6.CrossRefPubMedGoogle Scholar
  76. 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.PubMedGoogle Scholar
  77. 77.
    Gan SD, Orringer JS. Hemosiderin hyperpigmentation: successful treatment with Q-switched 755-nm laser therapy. Dermatol Surg. 2015;41(12):1443–4.CrossRefPubMedGoogle Scholar
  78. 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.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.University of Texas McGovern Medical School at HoustonHoustonUSA
  2. 2.Departments of Dermatology and Head and Neck SurgeryThe University of Texas MD Anderson Cancer CenterHoustonUSA
  3. 3.Department of DermatologyUniversity of Texas McGovern Medical School at HoustonHoustonUSA

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