Varicose eczema

Varicose eczema is a long-term skin condition that affects the lower legs. It's common in people who have varicose veins.

You may also hear it called venous eczema, gravitational eczema or stasis eczema.

Like all types of eczema, varicose eczema makes the affected skin:

• itchy
• red and swollen
• dry and flaky
• scaly or crusty

There may be periods when these symptoms improve and periods when they get worse.

Your legs may swell, especially towards the end of the day or after you've been standing for a long time. Varicose veins (swollen and enlarged veins) are often visible on the legs.

Some people have other symptoms as well, such as:

• brown discolouration of the skin
• red, tender and tight skin that can eventually become hardened (lipodermatosclerosis)
• small, white scars (atrophie blanche)
• pain
• eczema affecting other parts of the body

If varicose eczema is left untreated, leg ulcers can develop. These are long-lasting wounds that form where the skin has become damaged.

If you have symptoms of varicose eczema, see a doctor. They can often make the diagnosis just by looking at your skin.

Varicose eczema comes from increased pressure in the leg veins. Inside these veins are small valves, and when they stop working properly, blood has a hard time moving upwards against gravity and can leak backwards.

That raises the pressure in the veins, and the higher pressure can push fluid out into the tissue around them. It is thought that varicose eczema may develop because the immune system reacts to this fluid.

People with varicose veins get varicose eczema more often. Varicose veins are also usually a sign that the leg veins aren't working properly.

Varicose eczema tends to be a long-term problem, but there are treatments that help keep it under control.

For most people, treatment is a combination of:

• self-help measures, including ways to improve your circulation, such as keeping active and raising your legs often
• emollients, which are moisturisers applied to the skin to stop it becoming dry
• topical corticosteroids, which are ointments and creams applied to the skin to help treat the eczema and relieve symptoms
• compression stockings, which are specially made stockings, usually worn every day, that steadily squeeze your legs and help improve your circulation

If these treatments don't help, your doctor may refer you to a dermatologist (a skin specialist). This is in case there is another cause for your symptoms, or if they are concerned you may also have a type of eczema called contact dermatitis.

If you also have varicose veins, you may be referred to a vascular specialist (a doctor or surgeon who specialises in conditions affecting the blood vessels). They can talk to you about the treatment options for varicose veins.

Varicose eczema is usually caused by increased pressure in the veins of your legs.

Inside your veins there are valves. They let blood pass in one direction and stop it flowing backwards. Sometimes the walls of the veins get stretched and lose their elasticity, and this weakens the valves. When the valves don't work properly, blood may leak backwards.

That raises the pressure in your veins, and the higher pressure may push fluid out into the tissues around them. It's thought that varicose eczema may develop because your immune system reacts to this fluid in the tissues under your skin.

The same rise in pressure can also make blood collect in your veins. The veins then become swollen and enlarged, and these are called varicose veins.

Doctors don't fully understand why the walls of the veins stretch and the valves weaken. Some people develop varicose eczema for no obvious reason, but a few things do raise the chances of it happening:

• gender: varicose eczema is more common in women
• obesity: this can increase the pressure in your leg veins
• pregnancy: this can also increase the pressure in your leg veins
• not being able to move for a long period of time: this can affect the circulation in your leg veins
• having previously had deep vein thrombosis (DVT): these are blood clots that develop in leg veins, and they can damage the valves in your veins
• increasing age: people generally find it harder to move about as they get older, which can affect their circulation

See a doctor if you have symptoms of varicose eczema. Most of the time, they can make the diagnosis just by looking at the affected areas.

The doctor will also ask you some questions to find out whether there's a problem with the flow of blood in your leg veins, because this is the main cause of varicose eczema.

To help with the diagnosis, the doctor may ask if you have a history of:

• varicose veins (swollen and enlarged veins)
• deep vein thrombosis (DVT), which is a blood clot in one of the deep veins of your legs
• leg ulcers (areas of damaged skin that take several weeks to heal)
• cellulitis, an infection of the deeper layers of the skin and underlying tissue
• surgery or injury to your legs

The doctor may also check the pulse in your feet. They may carry out an ankle brachial pressure index (ABPI) test as well, to see if compression stockings are suitable for you.

The ABPI test compares blood pressure readings taken from your ankles and your upper arms. If there's a significant difference between the readings, it suggests a problem with the flow of blood in your arteries. In that case, compression stockings may not be safe to use.

Your doctor may send you to a specialist in a local hospital for further tests. This could be a vascular specialist (a doctor or surgeon who treats conditions affecting the blood vessels) or a dermatologist (a specialist in skin conditions). You may be referred if:

• you have varicose veins and changes to your skin, such as varicose eczema, lipodermatosclerosis (hard, tightened skin) or a history of leg ulcers
• you have very poor blood flow in the blood vessels in your legs
• your symptoms don't get better, despite treatment
• it is possible that you may have contact dermatitis

Treatment for varicose eczema is meant to improve the condition of your skin, ease your symptoms and help your circulation (blood flow).

For many people, this means long-term treatment with a combination of:

• emollients (moisturisers)
• topical corticosteroids
• compression stockings

There are also some self-help techniques you can try. Each of these options is described in more detail below.

Lipodermatosclerosis (hardened, tight skin) is treated in a similar way to varicose eczema. If you have a venous leg ulcer, you can also read about treating venous leg ulcers.

There are some steps you can take to ease the symptoms of varicose eczema and help prevent further problems:

• try to avoid injuring your skin, because an injury could lead to an ulcer developing
• raise your legs when you are resting, for example by propping your feet up on some pillows (ideally so they are above the level of your heart), as this can help reduce swelling
• keep physically active, as this will improve your circulation and help you maintain a healthy weight

Fluid can build up in the lower legs if you sit or stand for too long, so it's important to keep moving. Walking gets your muscles working and helps push the blood through the veins back to your heart.

The National Eczema Society also recommends regularly flexing your feet and rising up onto your toes, or bending down at the knees.

Emollients are moisturising treatments that you apply straight onto the skin. They cut down water loss and cover the skin with a protective film. Doctors often suggest them for dry or scaly skin conditions, and varicose eczema is one of these, as is other eczema.

There are quite a few emollients to choose from. Some you can buy over the counter without a prescription, but if you have varicose eczema, it may help to ask your doctor to recommend a suitable one.

You may have to try several before you find the one that works for you. You may also be prescribed a mixture of emollients, for example:

• an ointment for very dry skin
• a cream or lotion for less dry skin
• an emollient to use instead of soap
• an emollient to add to bath water or use in the shower

What separates lotions, creams and ointments is how much oil they contain. Ointments have the most oil, so they can feel quite greasy, but they are the most effective at keeping moisture in the skin. Lotions have the least oil, so they aren't greasy, but they can be less effective. Creams sit somewhere in between.

If you have varicose eczema, use an emollient at least twice a day, even on days when you have no symptoms.

Here is how to apply it:

• use a large amount, and try to cover all the skin on your lower leg, not just the parts that are obviously affected
• don't rub it in, but smooth it onto the skin in the same direction that the hair grows
• apply it every 2 to 3 hours if your skin is very dry
• after a bath or shower, dry the skin gently, then put the emollient on straight away while the skin is still moist
• do not share emollients with other people

Keep using emollients during a flare-up of varicose eczema too. This is when your skin needs the most moisture, so apply the emollient often and in generous amounts.

Emollients rarely cause side effects, but now and then they can cause a rash. Greasy emollients may sometimes cause folliculitis (inflammation of the hair follicles). If you notice any side effect from your emollient, speak to your doctor, who can prescribe a different product.

Emollients added to bath water can make the bath very slippery, so take care when you get in and out.

When your skin is inflamed from a flare-up of varicose eczema, your doctor may prescribe a topical corticosteroid to bring the inflammation down quickly. This is a corticosteroid medicine that you apply directly to the skin, as a cream or ointment. You may also hear it called a topical steroid.

The strength of the topical corticosteroid depends on how severe your varicose eczema is, so different strengths can be prescribed. If you have flare-ups of lipodermatosclerosis, you may need a very strong topical corticosteroid.

Apply a topical corticosteroid only to the affected areas of skin. Your doctor can tell you how much to use and how often, and the patient information leaflet that comes with your medicine has advice too.

Most people only need to apply a topical corticosteroid once a day. When you apply it, follow these points:

• apply your emollient first and wait around 30 minutes before applying the topical corticosteroid (until the emollient has soaked into your skin)
• apply it only to the affected area
• use the topical corticosteroid for 7 to 14 days and continue to apply the treatment for 48 hours after the flare-up has cleared

If your varicose eczema is moderate to severe, you may need to apply topical corticosteroids both between flare-ups and during them.

If you need to use topical corticosteroids on a long-term basis, you should apply them less often. Your doctor will advise you on how often to apply them.

You should also speak to your doctor if you have been using a topical corticosteroid and your symptoms have not improved.

Topical corticosteroids can cause a mild burning or stinging feeling when you put them on, and it passes quickly. This is more likely if you're using a cream.

Using a strong topical corticosteroid for a long time raises your risk of more serious side effects, such as thinning of the skin. Your doctor will tell you what strength of medicine you need and when to use it.

Medical compression stockings are made to squeeze your legs steadily, and this helps your circulation. They are tightest at the ankle and get a little looser the further up the leg they go. That pattern encourages blood to flow upwards, towards your heart.

Doctors use these stockings to treat varicose eczema and lipodermatosclerosis. They improve the flow of blood through the veins in your legs and bring down the pressure inside those veins.

Compression stockings come in different sizes and pressures. You can also choose between other features:

• different colours
• different lengths, since some come up to the knee and others also cover the thigh (for varicose eczema you should only need knee-high stockings)
• different foot styles, since 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. Stockings that compress the legs more are available on prescription, and a nurse will need to measure you first.

If you find it difficult to put on your stockings, you may in some cases be advised to use a tubular bandage instead.

You'll usually need to put your compression stockings on as soon as you get up in the morning, and take them off when you go to bed. They can be uncomfortable, especially in hot weather, but wearing them the right way gives you the most benefit from them.

Pull them all the way up, so each part of your leg gets the correct level of compression. Don't let a stocking roll down, because it may dig into your skin in a tight band around your leg. If the stockings are uncomfortable, they don't seem to fit, or you have trouble getting them on, speak to your doctor. It may be possible to get custom-made stockings that fit you exactly.

Take care when you put the stockings on and when you take 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.

Compression stockings usually need to be replaced every 3 to 6 months. If your stockings get damaged, speak to your doctor, because they may no longer work as they should. You should be prescribed 2 stockings (or 2 sets, if you wear 1 on each leg), so you can wear one while the other is being washed and dried. Wash compression stockings by hand in warm water, and dry them away from direct heat.

If you have varicose veins as well as varicose eczema, treating the veins can sometimes help.

If your doctor thinks treatment may be worthwhile, they can refer you to a vascular surgeon. The surgeon can arrange an ultrasound scan of your leg to find the faulty blood vessels, and your treatment can then be planned.

Several treatments can improve the symptoms and appearance of varicose veins, including:

• endothermal ablation, where energy from either high-frequency radio waves or lasers is used to seal the affected veins
• sclerotherapy, where a special foam is injected into your veins to seal them
• ligation and stripping, where affected veins are tied off and surgically removed

These procedures are usually done in the day surgery department of a hospital.