Eczema - gravitational eczema

What is gravitational eczema?

Gravitational eczema, also known as venous, varicose, or stasis eczema, is the name given to a type of eczema on the lower legs. The word eczema (or dermatitis) refers to a common inflammatory skin condition.

What does gravitational eczema look and feel like?

Features of gravitational eczema include any of the following:

• Often affects both lower legs, although one leg may be affected more than the other
• It is usually itchy, and can be dry and scaly, or wet and weepy
• Areas of active eczema are pink-red. In skin of colour the affected skin may be darker than the surrounding skin
• Brown discoloration is a common feature in many people

Gravitational eczema is sometimes incorrectly diagnosed as cellulitis (a skin infection) and treated incorrectly with long courses of antibiotics. Cellulitis is nearly always unilateral (affecting only one leg) and causes a painful/tender spreading red area (or darker patch in skin of colour). People with cellulitis soon feel unwell and develop a temperature. If you think you have cellulitis you must seek urgent medical treatment. For more information refer to this link on cellulitis.

What causes gravitational eczema?

When small valves in the leg veins stop working properly it becomes difficult for blood to be pushed upwards against gravity and it can leak backwards. This increases pressure in the veins, forcing fluid out into the surrounding tissue, which then triggers inflammation and other features associated with gravitational eczema.

Factors associated with these changes include increasing age, gender (more common in women), obesity, pregnancy, immobility, previous blood clots in the leg (venous thrombosis) and previous cellulitis (skin infection).

Things you can do to help yourself

The following steps may help reduce the symptoms of gravitational eczema and may help prevent other problems sometimes associated with gravitational eczema.

• Try to avoid knocking/banging your legs as this could lead to an ulcer developing, which can be very slow to heal

• Simple measures are particularly important in helping to improve blood flow within your legs and reducing pressure in the veins:
• Keep physically active; and if you are overweight, losing weight can help
• Fluid can build up in your lower legs if you stand still for too long, so it's important to keep moving. Walking will get your muscles working, which squeezes the blood up through the veins and back to your heart. If you stand still for any length of time, then rising onto your toes or bending at the knees can also help
• When you are sitting down do not cross your knees as this will reduce how much blood moves out of your legs
• If your legs are swollen, raise your legs when resting, ideally above the level of your heart, eg by lying down and propping up your feet on some pillows. It can also help to raise the foot of the bed overnight
• Follow this link for more information on leg exercises

• Protect your skin by avoiding irritants such as soaps, bubble baths and detergents

• Help repair the skin barrier with emollient moisturisers - these come in the form of creams, gels, and ointments. Creams and gels are better tolerated, ointments are more effective if the skin is very dry. The most important aspects of emollients are – use the one that suits you best, use large amounts, apply to the all the skin on the lower legs (and to any other areas of eczema), aim to use twice a day as a minimum, and know how to apply. This link shows how to apply moisturisers (emollients)

• Do not wash (bath or shower) more than once a day, and for no more than 10-15 minutes - our skin does not like water. Avoid soaps and anything that makes a lather as this may damage the skin, instead consider washing with an emollient. Take care not to slip - using an emollient in the bath or shower is best avoided in people with poor balance and/or those who are more at risk of breaking a bone

• Keep nails short and clean to minimise damage to the skin from unintentional scratching 

• See your pharmacist and ask about treatments such as emollients and mild steroid creams that can be purchased without a prescription. If you pay for your prescriptions; ask about a pre-payment certificate

Make an appointment at your GP surgery

If your eczema is not responding to the measures described above, then make an appointment to see a health professional.

This link provides details on specific treatments.

General notes on treatment:

• Emollients - as discussed above. You must continue using these even if the eczema is settled, otherwise your eczema is likely to flare-up more often

• Steroid creams (or ointments, gels, lotions) - should be applied thinly and only to the affected patches of skin during flare-ups (when the skin becomes red and itchy). They must NOT be applied at the same time as a moisturiser, leaving a minimum of 20 minutes between the two applications (a good routine is important. Some people apply moisturisers in a morning and then after washing in an evening, followed by the steroid cream at bedtime). This link explains how to apply steroids onto the skin

• Topical calcineurin inhibitors (e.g. tacrolimus ointment) - steroid creams must not be applied to the lower legs on a long-term regular basis otherwise they will thin the skin. As an alternative you may be prescribed a topical calcineurin inhibitor, which can be used in addition to moisturisers to control the eczema. As with topical steroids, these must NOT be applied at the same time as a moisturiser, leaving a minimum of 20 minutes between the two applications. Steroid creams/ointments can still be used for a few days during a flare-up

• Antihistamines - in most people, non-sedating antihistamines (which do not make you feel tired) do NOT help eczema. Sedating antihistamines (which make you feel tired) may help at night if the eczema is flaring and affecting your sleep. You need to be mindful that sedating antihistamines may affect your driving / ability to work the next morning and should not be used regularly in the long-term as they may increase the risk of dementia

• To help move the blood out of your legs you may be recommended to wear compression stockings (see lower down in this leaflet), under which your emollients and topical steroids can still be used

Management of persistent moderate/severe gravitational eczema

• You may be prescribed a stronger (potent or super-potent) steroid cream/ointment to be used for a short period. These treatments are particularly effective if applied at night and covered with Clingflim. Alternatively, your GP may recommend using treatment under medicated bandages, e.g. ZIPZOCs ® or Viscopaste ® bandages. This link provides advice and videos on how to use these bandages

• If the eczema continues to be a problem it may be that you have developed an allergy to one of the creams/ointments, known as contact allergic dermatitis, in which case alternative treatments may be needed and/or you may need to be referred for patch testing, a type of allergy test

Referral to a specialist

The following groups of people may need to be referred to a specialist, who will be either a Dermatologist or a GPwER/GPwSI in Dermatology (a GP who has been trained in relevant areas of dermatology):

• If the diagnosis is unclear
• Possible cases of contact allergic dermatitis
• Moderate-severe eczema not responding to treatments provided by your health professional
• Associated conditions e.g. non-healing venous leg ulcers (most likely to be referred to a tissue viability team)

What will happen when you are referred?

The appointment may be face-to-face (the person attends the clinics), or a video call (Teledermatology).

Can gravitational eczema be cured?

Unfortunately, the problem of the valves in the veins not working properly cannot be cured; this means that the management of gravitational eczema is long-term.

In persistent and very troubling cases of gravitational eczema, the opinion of a vascular surgeon may be sought to assess whether a varicose vein operation may be helpful.

Compression stockings

Medical compression stockings are specially designed to steadily squeeze the muscles in your legs. They are tightest at the ankle and get gradually looser as they go further up your leg, helping improve the blood flow out of your veins towards your heart.

Choice of compression stockings 
Compression stockings are available in different sizes and pressures. They are also available in:

• Different colours
• Different lengths - some come up to the knee and others also cover the thigh
• Different foot styles - some cover the whole foot and some stop before the toes
  

Support stockings or tights that lightly compress the legs can be bought from pharmacies, however, compression stockings are more effective but are only available on prescription and require you to be measured by a health professional first.

Support / compressions stockings are not safe to wear if you have arterial disease in which not enough blood flows down your legs in your arteries - your nurse may need to do a blood pressure test known as the ankle brachial pressure index (ABPI) to check the blood flow in the legs before compression stockings can be prescribed.

Wearing compression stockings
You will usually need to put on your compression stockings as soon as you get up in the morning and take them off when you go to bed.

Wearing compression stockings can be uncomfortable, particularly during hot weather, but it is important to wear them correctly to get the most benefit.

Pull them all the way up so the correct level of compression is applied to each part of your leg. Do not let the stocking roll down, or it may dig into your skin in a tight band around your leg.

Speak to a health professional if the stockings are uncomfortable, they do not seem to fit, or you have difficulty putting them on. It may be possible to get custom-made stockings that will fit you exactly.

Take care when putting compression stockings on and taking them off, as this can damage fragile skin. If you have a leg ulcer, it ideally needs to heal before you start wearing compression stockings.

Caring for compression stockings
Compression stockings usually need replacing every 3-6 months, or sooner if they get damaged.

You should be prescribed 2 stockings (or 2 sets of stockings if you are wearing 1 on each leg) so that 1 pair can be worn while the other is being washed and dried. Compression stockings should be hand-washed in warm water and dried away from direct heat.

Not all people manage / tolerate compression stockings - some find it too difficult to put them on (e.g. if you have arthritis), others may find them too uncomfortable. If you notice that the skin is starting to break down or ulcerate you must stop wearing stockings and inform your health professional immediately as this may suggest that the stockings are preventing enough blood flowing down the legs.

CAUTION

This leaflet mentions ‘emollients’ (moisturisers). When emollient products come into contact with dressings, clothing, bed linen or hair, there is a danger that a naked flame or cigarette smoking could cause these to catch fire. To reduce the fire risk, patients using skincare or haircare products are advised to be incredibly careful near naked flames to reduce the risk of clothing, hair or bedding catching fire. Cigarette smoking (and being close to people who are smoking) should be avoided.

Helping with other skin conditions

If you, a family member, or friend have an undiagnosed skin condition; or you want to learn more about how to treat skin conditions, please view our short video on how to get the best from this website.