Photo Rounds

Rash on lower leg

A 65-year-old woman sought care for a pruritic rash on her lower legs. She also indicated that when she stood for long periods of time, she developed swelling in both of her legs. The family physician (FP) noted hyperpigmentation, scale, atrophy, erythema, and purplish discoloration of the lower legs, as well as varicose veins around the knees and upper legs.

What's your diagnosis?


 

The FP diagnosed lipodermatosclerosis, venous stasis dermatitis, and venous insufficiency in this patient. All of the skin changes were secondary to the venous insufficiency.

Venous insufficiency, or improperly functioning valves in the venous system, can lead to a variety of symptoms, including heaviness and/or swelling in the legs with prolonged standing, leg fatigue or aching, bleeding from leg varices, skin changes, and ulcerations.

Venous insufficiency occurs more frequently in women than in men. Varicose veins are notable only in half of patients with venous insufficiency. Venous insufficiency is typically a result of valvular dysfunction, which may be primary or secondary (the result of trauma or deep venous thrombosis). It may affect the deep system (eg, femoral vein), superficial system (eg, saphenous vein), or both. Dysfunction leads to a loss of compartmentalization of veins, which results in distention and increased pressure. Increased pressure in veins is transmitted to the microvasculature, leading to basement membrane thickening, increased capillary elongation, and visual skin changes.

In this case, the FP recommended graduated compression hose to treat the venous insufficiency. Compression hose treat symptoms—not underlying pathophysiology. The skin changes were treated with 0.1% triamcinolone ointment to improve the symptoms and decrease the dermatitis. (The pigmentary changes and atrophy are not reversible.)

The FP also discussed other treatment options, including endovenous ablation or stripping and ligation if the superficial system is involved. Endovenous therapy uses radiofrequency or laser energy to ablate the vein. Because the vein is usually accessed with a needle under ultrasound guidance, an incision is avoided.

Photo courtesy of Maureen Sheehan, MD. Text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Sheehan M. Venous insufficiency. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine, 2nd ed. New York, NY: McGraw-Hill; 2013:295-298.

To learn more about the Color Atlas of Family Medicine, see: http://www.amazon.com/Color-Family-Medicine-Richard-Usatine/dp/0071769641/

You can now get the second edition of the Color Atlas of Family Medicine as an app by clicking this link: http://usatinemedia.com/

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