What is varicose eczema?
Varicose eczema, also known as ‘gravitational eczema’ or ‘stasis eczema’, is a common skin condition that affects the lower legs of adults. If left untreated, the skin can break down to form ulcers. Here, we explain what causes varicose eczema and how it can be treated in the early stages to help prevent ulcers from developing.
Who gets varicose eczema?
Varicose eczema is quite common, affecting approximately 70 per cent of people over the age of 70. Varicose eczema can occur in younger people, too, if they have a genetic predisposition to varicose veins. You are most likely to develop this type of eczema if you have high blood pressure or varicose veins, or have had a deep vein thrombosis (a blood clot in the leg vein), phlebitis (inflammation of the vein wall) or cellulitis (infection in the skin) in the past. Other contributing factors include being overweight, immobility, and swelling caused by prolonged standing or hot weather. Trauma to the skin, such as an injury or bad insect bite, can also be a contributing factor. Varicose eczema is more common in women than in men since female hormones and pregnancy increase the risk of developing the condition.
What causes varicose eczema?
In all age groups the blood flow in the veins is slower, with less pressure, than in the arteries. To help the blood flow in one direction and prevent back flow there are valves along the veins at regular intervals. The muscle walls of the veins are thinner than those of the arteries and the veins rely on other muscles (e.g. the calf muscles) to help massage the blood flow. Since the veins in the lower legs are furthest from the heart, this area of the body is particularly vulnerable to poor circulation.
Many of us will have noticed our feet swelling if we sit still on a long flight. This is due to our immobility on the plane and the pressure in the veins increasing as the blood flows more slowly back up our legs to our heart. The increased blood pressure in the veins forces fluid out of them into the surrounding tissues, which leads to swollen, puffy feet. As we disembark and start to walk around, or elevate the feet overnight in bed, the swelling disappears.
In normal veins, the valves allow blood to flow up but not down the legs. The calf muscles contract when you walk, pumping blood up the legs towards the heart. When the valves are less efficient from ageing or damage, blood flows in two directions and pools, causing increased pressure and sometimes bulging in the veins (varicose veins). Over time the pressure can result in swelling of the leg, especially the ankles, and fluid may leak into surrounding tissue producing mottled discolouration and inflammation leading to varicose eczema. The skin may become thicker and darker (lipodermatosclerosis) and there is a risk of ulceration. Abnormal vein function such as this is known as ‘venous insufficiency’.
Varicose eczema manifests as itchy, dry, flaky areas of skin. The skin may also change colour and become weepy and crusty. When the eczema settles, the skin may crack if it becomes over-dry, or break down if scratched or picked. The skin on the lower leg generally becomes fragile – a knock to that area, with a shopping trolley, for example, can also break the skin and cause further irritation, with the risk of a leg ulcer developing.
What causes a varicose ulcer?
Skin affected by varicose eczema is thin and unhealthy and can easily break down – as soon as this happens, the area should be treated to help the skin heal quickly. If left untreated, the small hole can deepen and widen, and the resulting wound is called a ‘varicose ulcer’ (also known as a ‘venous ulcer’ or ‘stasis ulcer’). These ulcers are typically found just above the inside of the ankle. They often ooze and can attract bacteria, both of which can aggravate the surrounding skin, making the eczema even worse. Sometimes events can occur the other way round – varicose eczema can develop for the first time around an existing ulcer or wound on the lower leg, but treatment remains the same.
How can I reduce the risk of developing varicose eczema?
There are a number of steps you can take to reduce the risk of developing varicose eczema. One key step is to improve the blood circulation in the legs; for example, by walking more, if possible, and elevating the legs when seated.
If you have varicose veins, or have had phlebitis or a deep vein thrombosis, you will need to give extra care and attention to your legs for the rest of your life, since varicose eczema can occur years later. Try to lose weight, if necessary. If you need help with weight loss, talk to your practice nurse or consider joining a local weight-loss group.
Varicose veins can be treated, so consult your doctor if you think you have them. Veins near the surface of the leg are not essential and surgical removal by stripping the veins or, more commonly, removal by laser under local anaesthetic (endothermal ablation) will eradicate them. Sometimes a special injection (sclerotherapy) into the veins can help. The longer prominent varicose veins are left, the less successful surgical treatment is – so don’t ignore the problem; discuss it with your GP. Unfortunately, in some regions, varicose vein surgery or laser treatment is not available on the NHS.
If you have had phlebitis or thrombosis, or your varicose veins cannot be treated, your leg veins should be supported at all times. For mild cases which require low-strength compression, elastic support stockings or tights, available from most pharmacies, are adequate. For more severe varicose veins, compression hosiery is made to measure and can be prescribed by your doctor or nurse. If you have a venous ulcer, you will need compression bandages, which will be applied by a nurse when your leg ulcer is dressed. Your doctor or practice nurse will advise on which type of leg support is best for you, but the following tips may help:
- If you need to wear compression hosiery, this will usually be prescribed. It is important to have compression stockings fitted correctly. Your practice nurse or district nurse will usually do this and you should be measured when you are seated with your lower leg bent at 90 degrees.
- If compression hosiery is required, make sure you know how to put it on. This is often tricky at first, so don’t be afraid to ask your nurse if you are not sure.
- There are devices available to help you put your hosiery on, if required.
- Always put compression hosiery on before you get out of bed – your ankles are least swollen first thing in the morning, so put the stockings on before any fluid can build up.
- Ordinary stockings or tights can be worn over compression hosiery if you think it looks unsightly.
- Try not to stand still for long stretches of time. If you have to, then flex your feet frequently – for example, tap your feet, rise up onto your toes, or bend at the knee – as this will help to keep blood moving in the veins.
- It is better to sit or walk than to stand still, and it is even better to sit with your feet up. Whenever you get a chance to sit down, perhaps to watch television or read a newspaper, rest your feet up on a stool that is at least the same height as the chair. If possible, raise your legs even higher, so they are level with your chest, by lying on a bed or full length on a sofa. This will help to relieve aching legs and reduce ankle swelling.
- Exercise is important. A spot of brisk walking every two hours (even if you are inside the house) or, if you can, walking up stairs (rather than taking a lift) can make your leg muscles work and help push blood through the veins.
How is varicose eczema treated?
There are a number of treatments available to help keep your skin supple and prevent ulcers. All the tips on reducing the risk of developing varicose eczema should still be followed since these will also help to improve the eczema.
- Keep the skin soft and supple by applying an emollient to your legs at least twice a day, or more often if your skin is very dry (emollients are available on prescription from your doctor or over the counter at a pharmacy). Emollients can be used all over your body if your skin is generally dry. Lightly apply the emollient in smooth downward strokes so that the skin glistens. National Eczema Society has a factsheet on Emollients, which gives more details on the types of emollients available.
- People with varicose eczema sometimes develop an allergy to certain ingredients in creams, so find out what suits you. Ingredients likely to irritate the skin include perfumes, preservatives and occasionally lanolin, so avoid any product containing them.
- If you react to a lot of creams, your GP may suggest a visit to a dermatologist for patch testing to find out what you are sensitive to.
- Avoid using soap and bubble bath – these dry out the skin and can irritate the eczema. Use your emollient as a soap substitute – that is, apply it to wet skin in place of soap. Hot water will dehydrate the skin and cause itching, so bathe or shower in cool to warm water.
- Emollients can make the bath/shower slippery, so be careful and use an anti-slip mat.
- Don’t use liniments or alcohol rubs on your legs as these irritate the skin and dry it out further.
- Socks or compression hosiery and trousers will protect the lower legs, but make sure clothing doesn’t cut into the flesh – tops of stockings and socks should be loose-fitting.
- Moderate to potent topical steroids (steroid creams and ointments) are available from your doctor if the eczema is very itchy, but only apply them to areas of active eczema. Never use a cream or ointment prescribed for someone else’s eczema.
- Bandages covered in zinc oxide (zinc paste bandages BP or Zipzoc), with an outer bandage applied to prevent mess, can be very soothing when applied to the eczema. They help reduce scaliness and protect the skin from knocks and scratching. Your nurse or doctor can prescribe paste bandages, and your nurse will need to teach you how to apply them properly. National Eczema Society has a booklet, Paste Bandages and Wet Wraps, with step-by-step images and instructions. Paste bandages are messy, however, and can sometimes irritate the skin. Occasionally, allergies may develop, so tell your doctor if your eczema gets worse after using them.
- If the skin becomes hot and inflamed, begins to ooze or look different, or if you feel feverish and sweaty, see your doctor, since this could be the start of a skin infection. If antibiotic tablets are prescribed, always complete the whole course, even if your skin soon looks better.
- If the skin is oozing and crusty, a wet soak may be advised – usually potassium permanganate dissolved in water (prescribed as Permitabs). A tablet is put in a bucket of water and should dilute to a pale pink ‘rosé wine’ colour. Soak the leg in this solution, or soak a flannel in it, and leave on the area for 15 minutes. This treatment does stain your skin (and the bath etc.), so use it carefully!
Will I always have varicose eczema?
This type of eczema can be an ongoing problem. The condition can become worse and then settle down, but if you have a good skin care routine, and are taking steps to support the blood circulation in the legs; together, these actions will help prevent flare-ups.
Don’t be too worried if varicose eczema appears – extra care and attention to the area can often clear the problem and prevent the skin breaking down. However, you may be left with some discolouration of the skin as part of the post-inflammatory process.
Preventative measures are very important and should be continued long-term – you will find that once you get into a routine, they will soon become a way of life!
To obtain the information on this page in a PDF format, please download our Varicose eczema factsheet, below.