Consider the following scenario: A district nursing team receives a referral for Mrs C—one of their former patients. Mrs C previously had a venous leg ulcer but, much to the team's satisfaction, this eventually healed. The referral says Mrs C's legs have ‘broken down’. When she is visited, it is found that she has not developed a new leg ulcer; instead, she has a weeping eczema rash on both of her legs. This is causing her a lot of distress. She has venous eczema, but what should the team do about it?
Though fictional, this could be a common scenario for many district nursing teams. About 37–44% of people with leg ulcers also have venous eczema (Patel et al, 2001), and like most other eczemas, it is unpleasant. It is also known as varicose, gravitational or stasis eczema (NHS England, 2023), but for this article it will be referred to as venous eczema.
This article will consider what venous eczema is and what causes it, how it effects a patient's life, how to manage it and how to prevent further reoccurences.
What is venous eczema?
Venous eczema is a rash that affects the skin of the lower legs (Gawkrodger, 2006). It is not caused by any infection (non-infective) and does not cause the affected area to swell (non-inflammatory); these are important factors as they distinguish it from cellulitis. It is very important to be able to differentiate between venous eczema and cellulitis (Nazarko, 2009), which will be discussed later in this article.
The affected skin will be red, itchy and scaly; it may ooze, crust and even crack; it always affects both legs (Nazarko, 2009). Initially, in its acute stage, venous eczema presents as a red and itchy rash, with tiny clear blisters that can weep (Brown, 2011). Once chronic, the skin becomes dry and scaly (Brown, 2011). On paler skin it looks red or brown, but on black or brown skin it looks dark brown, purple or grey, which can sometimes be more difficult to see (NHS England, 2023).
What causes venous eczema?
Like venous leg ulcers, it is a symptom of venous disease in a patient's lower legs (Nazarko, 2009). The individual may present with no symptoms, or in the other extreme, with leg ulcers (Nazarko, 2009). These symptoms have been listed into the Clinical, Etiological, Anatomical and Pathophysiological (CEAP) framework, which also tracks the severity of the condition (Table 1). However, venous eczema can be present without the patient having a leg ulcer (Nazarko, 2009).
Table 1. CEAP† classification of chronic venous disorders
| Classification | Description |
|---|---|
| C0 | No visible or palpable signs of venous disease |
| C1 | Telangiectasies (spider veins) or reticular veins |
| C2 | Varicose veins, distinguished from reticular veins by a diameter of 3 mm or more |
| C3 | Oedema |
| C4 | Changes in skin and subcutaneous tissue secondary to chronic venous disease, divided into two sub-classes to better define the differing severity of venous disease |
| C4aC4b | Pigmentation or eczemaLipodermatosclerosis or atrophie blanche |
| C5 | Healed venous ulcer |
| C6 | Active venous ulcer |
Note:
†Clinical (C), Etiological (E), Anatomical (A), and PathophysiologicaL (P);
Adapted from Eklöf et al (2004)Venous eczema is an indication that a patient is suffering from venous disease. This develops when the deep veins in a patient's legs are damaged by conditions that raise the pressure within the veins (Nazarko, 2010). The following factors increase a patient's risk of developing it:
- Gender: venous insufficiency is more common in women
- Obesity: this can increase the pressure in leg veins
- Pregnancy: especially multiple pregnancies
- A family history of venous insufficiency
- Being immobile for long periods of time
- Previous history of a deep vein thrombosis
- Increasing age: more prevalent as people age (NHS England, 2023).
Veins contain bileaflet valves, which prevent the backflow of blood along the vein; they only open when blood flows in one direction and if the blood backflows they close, thereby aiding blood flow back to the heart (Nazarko, 2009). High blood pressure stretches the bileaflet valve, pushing it apart, and this phenomenon, when occuring over long time, can damage it (Nazarko, 2010). Once a valve is damaged, it will have a knock-on effect on the other valves; the damage leads to further increase in pressure, which leads to the failure of the next valve and so on (Nazarko, 2009).
Around 3% of adults have changes to their skin due to venous disease (Fowkes, 2006), and around 20% of people over 70 years have venous disease (Nazarko, 2010). Additionally, two-thirds of patients with venous eczema are obese (Grey et al, 2006).
Venous eczema is a symptom of venous disease (Nazarko, 2009) and therefore should not be ignored.
The psychosocial effects of venous eczema on patients
Mudge and Price (2005) found that patients with eczema experience stigmatisation, shame and impaired body image changes from living with a skin disorder. They also found patients' loss of self-esteem impaired on their social and physical relationships.
The All Party Parliamentary Group on Skin report (2003) found dismissive attitudes to skin conditions from the general public, including repulsion, indifference or distaste from the misplaced belief that skin conditions are contagious or are caused by poor hygiene. They even found doubt that skin conditions count as sickness, especially as the government categorised them as ‘minor ailments’.
An elderly patient, with already reduced mobility from their swollen legs, has now developed a red, itchy rash, which could also be weeping; this would undoubtedly impact on their emotional and social life. Hence, management is key in maintaining patients' quality of life.
How to manage venous eczema?
Nazarko (2009) recommended that both treating the symptoms of venous eczema and managing the underlying pathology (the venous disease), are essential. This can be done through the following.
Self-help
There are several steps patients can take to help manage their venous eczema. Patients should not stand for long periods as this will worsen the swelling because of their impaired bileaflet valves (Nazarko, 2009). However, walking regularly will help reduce the swelling as it aids in venous return (Nazarko, 2009). When sitting, a patient should elevate their legs as high as it is comfortable (Nazarko, 2009).
Because of the drying effect soap has on the skin, it can strip the skin of its natural oils; therefore, patients should avoid soap, bubble baths and shower gels. Instead, they should use emulsifying ointments as a soap substitute (Nazarko, 2008).
Emollients
These will hold the moisture in the skin and help replace the lost moisture and lipids causing the dryness of venous eczema. Nazarko (2009) recommended using the more greasy, sticky and thickest of emollients because they have the highest lipid content. Unfortunately, not all patients find these types of emollients the most comfortable to use, often leaving their skin greasy. Nonetheless, there are a wide range of emollients available. Find the right emollient for the right patient. Patients will often have used emollients before and will know which ones are best for their skin. However, the choice of emollient can also be changed if a patient needs one with a higher lipid content—this can be determined if their skin is not resolving. Emollients should be applied at least daily. If a patient cannot manage this, they may require assistance from a relative or carer.
Steroids
Nazarko (2009) also suggested that topical steroids are essential to treat severe venous eczema, especially when it is red and very itchy. But Nazarko (2009) also warned that steroids should only be used for short, episodical periods, not long-term, due to the side-effects.
When applying topical steroids, use the fingertip guide. One fingertip full of topical steroid should cover an area of eczema the size of two flat palms (of the person applying it) (Van Onselen, 2013). An area of venous eczema covering a lower leg could require two fingertips of cream to cover it. Topical steroids should be applied after the legs have been washed/soaked but before emollients are applied (Nazarko, 2010).
Compression stockings
Venous eczema is a symptom of venous disease, therefore the action of compression stockings in controlling leg swelling is important in managing the venous disease (Nazarko, 2009). Compression stocking should always be applied following local guidelines and policies, and after a full leg assessment.
Managing oozing venous eczema
This can be one of the most distressing symptoms of venous eczema, staining clothes and furniture, and preventing patients leaving their homes or even having visitors to their homes.
Nazarko (2009) recommended the use of potassium permanganate soaks to dry up oozing from venous eczema. Nazarko (2009) stated that one tablet dissolves into four litres of warm water. Legs should be soaked daily for 10-20 minutes in a bucket lined with a plastic bag. Patients should be warned that potassium permanganate soaks will stain skin, hair, nails, clothes and towels; therefore, it should be rinsed off as soon as the soak is over. Soaks should be stopped as soon as the venous eczema has dried up, which, according to Nazarko (2009), should take only a few days.
Soft paraffin or Vaseline can be applied to a patient's toenails before their legs are soaked, as it can help prevent their nails from being stained by the potassium permanganate soak (Nazarko, 2010).
Venous eczema vs cellulitis
Venous eczema can be confused with cellulitis (Nazarko, 2009) and this could be a serious error. There are different symptoms between them and taken as a full assessment, it can indicate which is which (Table 2).
Table 2. Differences between venous eczema and cellulitis
| Venous eczema | Cellulitis |
|---|---|
| No change in temperature between affected and non-affected skin | Affected area is hot to the touch |
| Rash is itchy but not painful | Affected area is tender to the touch and area is painful |
| Affected area has diffuse edges | Affected area is well-demarcated |
| Rash is dry with scaling skin | Skin of affected area can peal or blister |
| Will affect both legs | Often only affects one leg |
| Both affected legs will be swollen, it will be pitting oedema and will be eased by elevating both legs. | Affected leg will be swollen, though it will be hard to the touch and not relieved by elevating the leg. |
Preventing the reoccurence of venous eczema
Venous eczema usually occurs in swollen legs where there is already an established venous disease (Nazarko 2009). Reducing the damage from venous disease will also help to reduce the risk of the reoccurence of venous eczema.
- Walking will aid venous return and help reduce swelling, though standing for long periods will increase swelling and should be avoided
- Raising legs when sitting or lying, especially when sleeping at night. Placing a pillow under the legs when a patient is sleeping will achieve this
- Daily application of emollients to help keep the skin hydrated and healthy. These may not need to be ones as high in lipids as were needed to treat the patient's venous eczema, but which ever one they find comfortable
- Avoid soaps and use an emulsifying ointment or soap substitute instead
- Encourage the patient to use compression stockings daily. If they do not have them or do not use them, consider assessing them for one, following local guidelines. They can be very effective in helping to manage a patient's swollen legs.
These are very similar to the strategy for managing venous eczema but with one difference—topical steroids should not be used to prevent venous eczema, but only as a short-term treatment (Nazarko, 2009).
Conclusion
Venous eczema is not just another rash or a ‘normal’ part of aging. It is a symptom of venous disease and therefore, should be taken seriously and managed accordingly. Its symptoms—itchy, dry skin and oozing—can have a serious impact on a patient's quality of life. However, its management can significantly improve a patient's life.
Venous eczema is a symptom of the continuation of the effects of chronic venous disease on a person's legs. Having venous eczema does not mean a patient will automatically develop a leg ulcer, but it does mean that they are at risk of developing one, and every district nursing team knows about the challenges they present. Simple management and prevention of venous eczema can also help reduce the risk of that patient developing a leg ulcer.