Eczema: gravitational eczema (syn. varicose eczema or stasis dermatitis)

Patient Information Leaflet
Link: Eczema - gravitational eczema

https://www.pcds.org.uk/patient-info-leaflets/eczema-gravitational-eczema

Gravitational eczema is a common form of eczema that occurs on the lower extremities in patients with chronic venous insufficiency. It may be a precursor to more problematic conditions, such as venous leg ulceration and lipodermatosclerosis.

This chapter is set out as follows:

• Age - adults and older patients
• Itch is common

Distribution

• Localised or diffuse involvement of the gaiter area
• Often bilateral

Morphology

• Erythema
• The skin may be dry and scaly, or weepy
• A brown discoloration of the skin is common and results from haemosiderin deposition
• Varicose veins may or may not be present
• Differential diagnosis - gravitational eczema is often misdiagnosed as cellulitis. Cellulitis is nearly always unilateral, tender and has a well demarcated edge

Step 1: general

• Refer to the top right of the page for a patient information leaflet available through a QR code or printable PDF

• Use copious emollients (as in atopic eczema) - prescribe no less than 500 g, and use at least twice a day. If the skin is very dry use an ointment. This link shows a video on how to apply moisturisers

Step 2: infection

• If the skin appears infected (asymmetrical erythema and tenderness, usually with pyrexia) treat empirically with an appropriate antibiotic eg flucloxacillin (with or without Penicillin V) or clarithromycin / erythromycin if penicillin allergy, for 10-14 days. DO NOT continue providing antibiotics to afebrile patients with erythematous lower legs, which almost certainly will be caused by the eczema 

Step 3: topical steroids   

• Topical steroids may be needed for itch - use the least potent preparation that controls the symptoms, with steroid free periods in order to reduce the risk of skin atrophy. This link shows a video on how to apply topical steroids

Step 4: topical calcineurin inhibitors

• If topical steroids are needed on a regular basis, once the eczema has settled change to a topical calcineurin inhibitor such as Protopic 0.1% ® ointment (Tacrolimus 0.1%) 

• Use the Protopic ® once a day for 6-8 weeks, and if the eczema remains settled then reduce the Protopic ® to maintenance therapy of twice a week, increasing back to once a day if the eczema become more active

• For any significant flares a topical steroid can be re-introduced and used until the flare settles  

• Adverse effects of topical calcineurin inhibitors include a burning sensation 

• National guidance states that topical calcineurin inhibitors can be initiated by any health professional experienced in treating eczema - this of course includes General Practitioners 

Step 5: persistent symptoms

• For stubborn patches or those cases that are moderate-severe at onset, one of the most effective treatments is the use of a potent or super-potent topical steroid (eg Betnovate-C ® ointment) under medicated bandages eg ZIPZOC ® or Viscopaste ®. The bandages should be replaced once or twice a week and the treatment continued until things settle, which will often take six to eight weeks. Please click on the following link for demonstrations on how to apply these bandages/dressings

• Consider the possibility of a contact allergic dermatitis to one of the treatments being used - this is more likely if there is eczematous spread to distant sites. Such patients will require patch tests 

Step 6: long-term

• Aim to promote treatment of underlying venous conditions by the use of leg exercises and compression hosiery 

• Additional notes on hosiery:
  • Ideally Class II below knee, open toe stockings - it is advisable for the practice nurse to check the ankle-brachial pressure index (ABPI) to make sure there is no significant arterial insufficiency that would exclude their use
  • Ready to wear (RTW) hosiery is available in 5-7 sizes, depending on which company is used
  • Custom Fit / Made to Measure (MTM) hosiery is available for legs that do not fit into the RTW range
  • Measuring, selection, and ordering instructions are specific to the company and type of hosiery - all available online
  • For more information refer to the chapter on hosiery