Stasis Dermatitis

and Leg Ulcers

Basic Dermatology Curriculum

Last updated June 8, 2011

1
 Module Instructions

The following module contains a number

of blue, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated interactive guide to clinical
dermatology and dermatopathology.
We encourage the learner to read all the
hyperlinked information.

2
 Goals and Objectives

The purpose of this module is to help medical students

develop a clinical approach to the evaluation and initial
management of patients presenting with stasis dermatitis
and leg ulcers.
By completing this module, the learner will be able to:
Recognize the clinical presentation of stasis dermatitis
List treatment and preventative measures for stasis
dermatitis
List the most frequent causes of leg ulcers and describe their
presentations
Describe proper wound care and treatment for leg ulcers
Discuss when to refer a patient with leg ulcers to a specialist3
Case One
Mrs. Lillian Paulsen

4
 Case One: History

HPI: Mrs. Paulsen is a 74-year-old woman who presents to the

dermatology clinic with leg discoloration for the past three
months. The rash does not hurt, but occasionally itches. She
has not tried any treatment.
PMH: diabetes (last hemoglobin A1c was 6.7), hypertension,
obesity. No history of atopic dermatitis.
Medications: ACE-inhibitor, thiazide diuretic, sulfonylurea
Allergies: none
Family history: noncontributory
Social history: lives with her husband in a nearby town
Health-related behaviors: no tobacco, drug use, or alcohol
ROS: no leg pain when walking or at rest 5
Case One, Question 1

How would you describe

her skin exam?

6
Case One, Question 1

Erythematous brown
hyperpigmented plaque with
fine fissuring and scale
located above the medial
malleolus on the left lower leg
Right leg with varicosities
Notice the asymmetry?
Palpation of the left leg
reveals firm skin suggestive
of fibrosis
7
 Case One, Question 2

What is the most likely diagnosis?

a. Atopic dermatitis
b. Cellulitis
c. Erysipelas
d. Stasis dermatitis
e. Tinea corporis

8
 Case One, Question 2

Answer: d
What is the most likely diagnosis?
a. Atopic dermatitis (adults with AD have a history of childhood
AD and a different distribution of skin involvement)
b. Cellulitis (cellulitis occurs more acutely, presents with fever
and pain, more erythema, well-demarcated and without
pruritus or scale)
c. Erysipelas (a form of cellulitis caused by acute beta-hemolytic
group A streptococcal infection of the skin)
d. Stasis dermatitis
e. Tinea corporis (would expect sharply marginated,
erythematous annular patches with central clearing) 9
 Diagnosis: Stasis Dermatitis

Stasis dermatitis typically presents with erythema,

scale, pruritus (itching), erosions, exudate, and crust
Usually located on the lower
third of the legs, superior to the
medial malleolus
Can occur bilaterally or
unilaterally
Lichenification may develop
Edema is often present, as well
as varicose veins and
hemosiderin deposits (pinpoint
yellow-brown macules)
10
More Examples of Stasis
Dermatitis

11
More Examples of Stasis
Dermatitis

12
 Venous Insufficiency

Stasis dermatitis is a cutaneous marker of

venous insufficiency.
Normally, venous blood returns from the
superficial venous system via perforating veins
into the deep venous system.
Venous stasis occurs when the valves in the
deep or perforating veins become incompetent,
causing reflux into the superficial system
(venous hypertension).
13
 Venous Insufficiency

Risk factors for venous insufficiency:

Heredity Obesity
Age (older) Prolonged standing
Female Greater height
Pregnancy
Chronic venous disease is extremely common
and is associated with a reduced quality of life
secondary to pain, decreased physical function,
and mobility
14
 Venous Insufficiency

Early signs of venous insufficiency:

Tenderness Telangiectasias
Edema Varicose veins
Hyperpigmentation
Late signs:
Lipodermatosclerosis (subcutaneous fat is replaced
by fibrosis that eventually impedes venous and
lymphatic flow leading to edema above the fibrosis)
Venous ulcers
Scars that appear porcelain white and atrophic 15
What happened here?

16
 Lipodermatosclerosis

Stasis dermatitis can lead to fat

necrosis with the end stage being
permanent sclerosis
(lipodermatosclerosis) with
inverted champagne bottle legs
as seen here
Patients with lipodermatosclerosis
may also have acute inflammatory
episodes that present with pain
and erythema (these episodes
can be mistaken for cellulitis)
17
What happened here?

18
 Elephantiasis Verrucosa Nostra

Inflammation of the draining

lymphatics (as occurs with
cellulitis) results in damage to
those vessels resulting in
lymphatic insufficiency
The overlying skin becomes
pebbly, hyperkeratotic, and rough
Ulceration in this setting (with
lymphatic and venous
insufficiency) is significantly
harder to treat and heal 19
 Case One, Question 2

Which of the following are complications of

venous insufficiency?
a. Cellulitis
b. Contact dermatitis
c. Recurrent ulceration
d. Venous thrombosis
e. All of the above
20
 Case One, Question 2

Answer: e
Which of the following are complications of
venous insufficiency?
a. Cellulitis
b. Contact dermatitis
c. Recurrent ulceration
d. Venous thrombosis
e. All of the above 21
 Complications of Venous
Insufficiency
Recurrent ulcers
Cellulitis (open wound
provides a portal of
entry for bacteria)
Contact dermatitis
(from topical agents
applied to stasis
dermatitis or ulceration)
Venous thrombosis 22
 Leg Ulcers and Contact
Dermatitis
Leg ulcers are subject to sensitization to products
used to treat wound healing, leading to contact
dermatitis.
This is due to the intrinsic allergenic properties of
many ointments and wound products, the duration
of use, and the disrupted skin barrier.
This chronic inflammation and resultant dermatitis
lead to poor wound healing and/or recurrence of
leg ulcers.
23
 Stasis Dermatitis: Treatment

It is important to treat both the dermatitis

and the underlying venous insufficiency
Application of super-high and high potency
steroids to area of dermatitis
Elevation (to reduce edema)
Compression therapy with leg wraps
Change wraps weekly, or more often if the
lesion is very weepy
24
Compression Therapy Works

PRIOR TO TREATMENT FOLLOWING TREATMENT 25

Case Two
Mr. Patrick Baily

26
 Case Two: History

HPI: Mr. Baily is a 50-year-old man who presents to his primary care
provider with pain in his left leg. He developed a weeping spot a
few weeks ago, which he tried treating with an over-the-counter
antibiotic ointment.
PMH: history of a DVT 5 years ago after a transatlantic flight, no
longer on anticoagulation, hypertension, type 2 diabetes
Medications: thiazide diuretic, ACE-inhibitor, glyburide, metformin
Allergies: none
Family history: father with type 2 diabetes and hypertension
Social history: lives with wife in an apartment, works in construction
Health-related behaviors: smokes 1 cigarette/day
ROS: as above
27
 Case Two, Question 1

How would you describe Mr. Bailys skin exam?

28
 Case Two, Question 1

Irregularly shaped ulcer

located on the medial
aspect of the left ankle,
erythematous border,
exudative
Without undermining
(unable to probe under
the edges)
Pedal pulses are
present, 1+
29
 Case Two, Question 2

Given the history and exam, what type of

ulcer is on Mr. Bailys left leg?
a. Arterial
b. Diabetic
c. Pressure
d. Venous

30
 Case Two, Question 2

Answer: d
Given the history and exam, what type of
ulcer is on Mr. Bailys left leg?
a. Arterial
b. Diabetic
c. Pressure
d. Venous

31
 Venous Insufficiency Ulcers

Active or healed venous leg ulcers occur in ~ 1% of the

general population
They typically appear as tender, shallow, irregular
ulcers with a fibrinous base that are always located
below the knee
Usually located on the medial ankle or along the line of
the long or short saphenous veins
Accompanied with leg edema, hemosiderin
pigmentation, +/- dermatitis of the leg
Patients may experience symptoms of aching or pain.
Discomfort may be relieved by elevation. 32
 Leg Ulcers

Causes of chronic leg ulcers include:

Venous insufficiency 45-60%
Arterial insufficiency 10-20%
Combination of venous and arterial 10-15%
Diabetic 15-25%
Malignancy, vasculitis, collagen-vascular diseases, and
dermal manifestations of systemic disease may present
as ulcers on the lower extremity
Smoking and obesity increase the risk for ulcer
development and persistence (independent of the
underlying cause) 33
 Case Two, Question 3

Which of the following is the most appropriate

next step in evaluating Mr. Baily?
a. Measure the blood pressure in the left arm
and left ankle
b. Obtain a skin biopsy
c. Treat the ulcer with topical antibiotics
d. Use electrocautery to stop the weeping

34
 Case Two, Question 3

Answer: a
Which of the following is the most appropriate next
step in evaluating Mr. Baily?
a. Measure the blood pressure in the left arm and left
ankle (Mr. Bailys DP pulse was weak suggesting possible
co-existent peripheral arterial disease)
b. Obtain a skin biopsy (not necessary unless the diagnosis
is unclear or the ulcer does not respond to treatment)
c. Treat the ulcer with topical antibiotics (no, in fact topical
antibiotic ointments may lead to a contact dermatitis)
d. Use electrocautery to stop the weeping (trauma may
worsen the wound instead of improve it) 35
 Ankle/Brachial Index (ABI)

Measure the ABI to exclude arterial occlusive

disease
Compression therapy (used to treat venous
insufficiency) is contraindicated in patients with
significant arterial disease
The ABI is the ratio of systolic blood pressure in
the ankle to the systolic blood pressure in the
brachial artery
Normal: 0.8
< 0.8 = indication of peripheral arterial disease 36
 Ankle/Brachial Index (ABI)

The ABI is reliable except in diabetes (may

be falsely high)
An ABI should be performed in all patients
with weak peripheral pulses, risk factors for
arterial occlusive disease (e.g. smoking,
diabetes, hyperlipidemia), and when ulcers
are in locations not consistent with venous
ulcers
37
 Venous Ulcers: Evaluation

In addition to assessment of the ulcer, the physical exam of

patients with leg ulcers should include the evaluation of
peripheral pulses, capillary refill time, peripheral neuropathy,
and deep tendon reflexes
Diagnosis of venous leg ulcers can be made clinically,
however, non-invasive vascular studies such as venous
duplex ultrasound and venous rheography can help
document the presence and etiology of venous insufficiency
Findings may warrant surgical intervention with endoscopic
venous laser ablation, which may prevent further complication
Surgical intervention tends to be more helpful when the venous
disease is limited 38
 Venous Ulcers: Treatment

Address the underlying cause (venous insufficiency) as

well as local wound care:
Leg elevation
Keep the wound moist with a primary dressing
Treat dermatitis with topical steroids
Compression therapy (except with an ABI < 0.8)
Apply external compression (applied over a primary dressing)
with a high compression system such as a multilayer bandage or
paste-containing bandage (e.g. Unnas boot, Duke boot)
Treat infection with debridement of necrotic or infected
tissues and use systemic antibiotics for infection
Measure the ulcer at each visit to document improvement39
 Wound Care: The Primary Dressing

Keep the wound moist. A moist wound

environment promotes healing compared to air
exposure
Choice of dressings is less important than the
program of ulcer treatment outlined on the previous
slide
Semipermeable dressings that allow oxygen and
moisture to pass through (but not water) have
made the treatment of leg ulcers easier and more
effective 40
 Venous Ulcers: Treatment

Patient education is crucial in successful treatment:

Avoid topical antibiotics in order to prevent sensitization and
development of contact dermatitis
Cleanse the wound with saline. Avoid products like betadine
and hydrogen peroxide to prevent skin breakdown
Avoid frequent manipulation of the wound. Dressings can be
changed as infrequently as once weekly.
Once healed, avoid reaccumulation and development of
ulcers with regular use of 20-30mmHg compression
stockings
Patients with venous ulcers that do not demonstrate
response to treatment (reduction in size) after 6 weeks
41
should be referred to dermatology or a wound care clinic
Case Three
Mr. Robert Lund

42
 Case Three: History

HPI: Mr. Lund is a 60-year-old man who presents to his primary care
provider with a painful sore on his right lateral leg. He reports a
history of a cramping pain in his calves when walking, but this
current pain is more localized to the skin.
PMH: hyperlipidemia, hypertension, angina (stable)
Medications: statin, thiazide diuretic, sublingual nitroglycerin when
needed, aspirin
Allergies: NKDA
Family history: father with an MI at age 65, mother with diabetes
Social history: lives with his wife, works in sales, 2 grown children
Health-related behavior: smokes pack of cigarettes/day, one glass
of wine nightly, no drug use
ROS: no shortness of breath or recent chest pain 43
 Case Three, Question 1

How would you describe Mr. Lunds skin exam?

44
 Case Three, Question 1

Punched out
appearing ulcer with
sharply demarcated
borders
Minimal exudation and
surrounding erythema
Dorsalis pedis pulse is
absent
ABI is 0.6
45
 Arterial Ulcers

Arterial ulcers are caused by peripheral arterial

disease
Occur on the lower leg, usually over sites of
pressure and trauma: pretibial, supramalleolar,
and at distant points, such as toes and heels
Appear punched out, with well-demarcated
edges and a pale base
Exudation is minimal
Associated findings of ischemia include loss of hair
on feet and lower legs, shiny atrophic skin 46
 Arterial Ulcers

Pulses (dorsalis pedis and posterior tibial) may be

diminished or absent
Stasis pigmentation and lipodermatosclerosis are
absent (unless patient also has venous disease)
Associated with intermittent claudication and pain
As disease progresses, pain and claudication may
occur at rest
Unlike venous ulcers, leg pain often does not
diminish when the leg is elevated
47
 Case Three, Question 2

Which of the following recommendations

should take priority?
a. Encourage him to ambulate
b. Encourage him to stop smoking
c. Make sure his blood pressure and
hyperlipidemia are under good control
d. Refer to a vascular surgeon

48
 Case Three, Question 2

Answer: d
Which of the following recommendations should
take priority?
a. Encourage him to ambulate
b. Encourage him to stop smoking
c. Make sure his blood pressure and hyperlipidemia are
under good control
d. Refer to a vascular surgeon (although all the
answer choices are correct, the main goal of therapy
is the re-establishment of adequate arterial supply)49
 Arterial Ulcers: Treatment

Refer to a vascular surgeon for restoration of

arterial blood flow with percutaneous or surgical
arterial reconstruction
Patients should stop smoking, optimize control of
diabetes, hypertension, and hyperlipidemia
Weight loss and exercise are also helpful
All types of ulcers require proper wound care as
outlined above in venous ulcer treatment

50
Case Four
Mr. Ryan Stricklin

51
 Case Four: History

HPI: Mr. Stricklin is a 46-year-old man who presents to his

primary care provider with lesions on the bottom of his foot.
He noticed these lesions a few months ago when he was
changing his socks at the gym. He reports keeping them
clean with hydrogen peroxide.
PMH: type 1 diabetes x 25 years, hernia repair 20 years ago
Medications: insulin (glargine and regular)
Allergies: none
Family history: noncontributory
Social history: lives alone, works as a realtor
Health-related behaviors: no tobacco, alcohol, or dug use
ROS: no fevers, sweats or chills 52
 Case Four: Skin Exam

Callus has been

debrided, revealing
ulcers on the plantar
foot
Able to undermine the
ulcers with a metal
probe, unable to track
the ulcer to the bone

53
 Diabetic (Neuropathic) Foot
Ulcers
Peripheral neuropathy, pressure, and
trauma play prominent roles in the
development of diabetic ulcers
Usually located on the plantar surface under
the metatarsal heads or on the toes
Repetitive mechanical forces lead to callus,
which is the most important preulcerative
lesion in the neuropathic foot
54
 Diabetic (Neuropathic) Foot
Ulcers
Lifetime risk of a person with diabetes
developing a foot ulcer is as high as 25%
Risk factors for foot ulcers include:
Cigarette smoking Poor glycemic control
Past foot ulcer history Peripheral neuropathy
Peripheral vascular dz Diabetic nephropathy
Previous amputation Visual impairment

55
 Diabetic Foot Ulcer:
Evaluation and Treatment
Diabetic patients with foot ulcers are often best managed in
a multidisciplinary setting (podiatrists, endocrinologists,
dietician)
Remove the callous surrounding the ulcer (together with
slough and non-viable tissue)
Probe the ulcer to reveal sinus extending to bone or
undermining of the edges where the probe can be passed
from the ulcer underneath surrounding intact skin
Order an imaging study if concerned about bone
involvement
Patients with suspected osteomyelitis should be admitted to
the hospital for evaluation and treatment 56
 Diabetic Foot Ulcer:
Evaluation and Treatment
Use dressings to maintain a moist environment
Application of platelet-derived growth factor gel
has been shown to improve wound healing in
diabetic foot ulcers
Protect the ulcer from excessive pressure
Redistribute plantar pressures with casting or special
shoes (a podiatrist with expertise in the management
of the diabetic foot is extremely helpful)
Restrict weight bearing of the involved extremity
57
 Case Four, Question 1

Which of the following statements about Mr.

Stricklin is likely to be true?
a. He has diabetic neuropathy
b. He should continue to use hydrogen peroxide
to keep his lesions clean
c. He should wear open-toed shoes
d. None of the above

58
 Case Four, Question 1

Answer: a
Which of the following statements about Mr. Stricklin
is likely to be true?
a. He has diabetic neuropathy (diabetic neuropathy can
cause a loss of protective pain sensation as well as motor
dysfunction)
b. He should continue to use hydrogen peroxide to keep his
lesions clean (not true. Hydrogen peroxide interferes with
wound healing)
c. He should wear open-toed shoes (diabetic patients
should avoid open-toed and pointed shoes)
d. None of the above
59
 Diabetic Foot Ulcers: Prevention

Education about ulcer prevention should be provided for all

diabetic patients
Glycemic control is essential in preventing diabetes associated
complications, including peripheral neuropathy
Patients should receive annual foot examinations, with a clinical
assessment for peripheral vascular disease and monofilament test
for peripheral neuropathy
Patients should examine their own feet regularly
If present, treat tinea pedis (to prevent the associated skin barrier
disruption)
Encourage smoking cessation (risk factor for vascular disease and
neuropathy)
Optimize treatment of hypertension, hyperlipidemia, and obesity
60
 Case Five
Mrs. Melinda Dellinger

61
 Case Five: History

HPI: Mrs. Dellinger is a 50-year-old woman who presents to her

primary medical provider with a 4-day history of new, very painful
lesions on her hand and thigh. She initially thought these lesions
were bug bites, but they now appear to be expanding and look
more like ulcers.
PMH: inflammatory bowel disease (well-controlled)
Medications: sulfasalazine daily, multivitamin, fish oil
Allergies: no known drug allergies
Family history: brother with ulcerative colitis
Social history: lives with husband and 20-year-old daughter, works
full-time as a high school teacher
Health-related behaviors: reports no alcohol, tobacco, or drug use
ROS: no fevers, joint pains, abdominal pain or diarrhea 62
 Case Five, Question 1

How would you describe the following skin findings?

63
 Case Five, Question 1

Ulcer with
undermined (able
to probe
underneath)
violaceous border,
exudative

64
 Case Five, Question 2

Given the history and exam findings, Mrs. Dellingers

primary care provider is concerned about pyoderma
gangrenosum (PG) and made an urgent referral to the
dermatology clinic.
Which of the following is true about PG?
a. A biopsy of PG is diagnostic
b. Debridement of the ulcer will help the healing process
c. PG is a slow process
d. PG is often mistaken as a spider bite
e. PG is painless
65
 Case Five, Question 2

Answer: d
Which of the following is true about PG?
a. A biopsy of PG is diagnostic (Not true. There are no specific
histological features on skin biopsy)
b. Debridement of the ulcer ill help the healing process (No! In
fact, PG is triggered and made worse by trauma a process
called pathergy)
c. PG is a slow process (Not true. PG rapidly progresses)
d. PG is often mistaken as a spider bite (True! In fact, we
recommend you consider PG or MRSA when the diagnosis
of a brown recluse spider bite is at the top of your differential)
e. PG is painless (Not true. PG is often very painful)
66
 Pyoderma Gangrenosum (PG)

PG is an inflammatory ulcerative process mediated by an

influx of neutrophils into the dermis
Begins as a small pustule which breaks down and rapidly
expands forming an ulcer with an undermined violaceous
border
Satellite ulcerations may merge with the central larger
ulcer
Rapid progression (days to weeks)
Can occur anywhere on the body (most frequently
occurs on the lower extremities)
Can be very painful 67
 Pyoderma Gangrenosum

PG is triggered by trauma (pathergy), including insect bites,

surgical debridement, attempts to graft
PG is often misdiagnosed as a brown recluse spider bite
Though the majority of patients with PG do not have an
underlying condition, PG is often associated with a wide
range of other pathologies that the patient should be
evaluated for
Inflammatory bowel disease (1.5%-5% of patients get PG),
rheumatoid arthritis, hematologic dyscrasias, malignancy
1/3 of PG patients have arthritis: seronegative, asymmetric,
monoarticular, large joint
68
Another Example of PG

Note the undermined violaceous border

69
 PG: Evaluation and Treatment

PG should be considered a dermatologic emergency and

an urgent referral to a dermatologist should be considered
The diagnosis of PG is one of exclusion; there are no
specific histological or clinical features
Although non-diagnostic, a skin biopsy is often performed
to exclude other conditions
Treatment of the underlying disease may not help PG
(often doesnt)
Topical therapy: Superpotent steroids, topical tacrolimus
Systemic therapy: Systemic steroids, cyclosporine,
tacrolimus, cellcept, thalidomide, TNF-inhibitors
70
 Take Home Points Chart

Characteristic Arterial Ulcer Venous Ulcer Diabetic Ulcer

Medial region of the lower On soles, over bony
Location Ankle, toes, and heels
leg prominences
Irregular margin, Irregular margin, sloping Overlying callus,
Appearance punched out edges, little edges, pink base, usually undermined, red, often
exudate exudative deep and infected
Skin temperature Cold and dry Warm Warm and dry
Mild-moderate, unless
Pain Present, may be severe infected or with significant May be absent
edema
Arterial pulses Diminished or absent Present Present or absent
Loss of sensation, reflexes,
Sensation Variable Present
and vibration sense
Erythema, edema,
Shiny and taut, edema
Skin changes hyperpigmentation, Shiny, taut, or doughy
71
not common
lipodermatosclerosis
Refer to vascular Compression is mainstay, Remove callus, off-load
Treatment
surgeon, wound care wound care pressure
 Take Home Points

Stasis dermatitis is a cutaneous marker for venous

insufficiency
The most common types of leg ulcers include venous,
arterial, combined (venous and arterial), and diabetic
Diagnosis of leg ulcers may be made clinically, but
evaluation with non-invasive vascular imaging and the
ABI will often guide treatment
Treatment of venous leg ulcers includes leg elevation,
compression, and wound care
Patients with arterial ulcers should be referred to a
vascular surgeon for restoration of arterial blood flow 72
 Take Home Points

A callus is the most important preulcerative lesion

in the diabetic foot
Osteomyelitis should be considered in patients
presenting with diabetic foot ulcers
Education about ulcer prevention should be
provided to all diabetic patients
The diagnosis of PG should be considered in the
rapidly expanding painful ulceration of the lower leg
PG is a dermatologic emergency and patients
should be referred to a dermatologist 73
 Acknowledgements

This module was developed by the American

Academy of Dermatology Medical Student Core
Curriculum Workgroup from 2008-2012.
Primary authors: Sarah D. Cipriano, MD, MPH;
Timothy G. Berger, MD, FAAD.
Peer reviewers: Theodora Moro, MD; Patrick
McCleskey, MD, FAAD; Peter A. Lio, MD, FAAD.
Revisions and editing: Sarah D. Cipriano, MD, MPH;
John Trinidad.
Last revised June 2011. 74
 End of the Module

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