Varicose eczema is a skin condition caused by increased pressure in the veins of the legs. It usually affects older people. It often takes a long time to heal. Moisturisers (emollients), steroid ointments and compression stockings are the common treatments. Conditions such as infection and contact dermatitis can hamper progress. Surgery is occasionally required.
What is varicose eczema?
This is the term used for skin changes that happen when the pressure in the veins of the legs (venous pressure) increases. You may also hear it called gravitational eczema, stasis eczema or venous eczema.
What are the symptoms of varicose eczema?
Affected skin typically becomes red. The redness can sometimes come on quickly and be mistaken for infection (cellulitis). You may notice the skin also becoming scaly or flaky. Dirty brown or rusty brown patches of discolouration may develop. You may also get blisters or ulcers and the skin may feel hard or tight. It may be itchy or it may become painful.
The changes usually occur on the inner side of the calf. They usually start just above or around the ankle. Skin hardening and tightening are more obvious in the lower part of the leg. This can change the shape of the leg and cause an appearance that is like the shape of an upside down champagne bottle.
You may get some scarring in the later stages. Sometimes healed ulcers can leave a star-shaped white mark. The picture above is of a fairly severe case of varicose eczema.
Who gets varicose eczema?
Varicose eczema mainly affects older people. As many as one in five people over the age of 70 develop varicose eczema. People most at risk are those who have varicose veins, who have had varicose vein surgery, or who have had a thrombosis in a deep leg vein (a DVT - deep vein thrombosis).
What causes varicose eczema?
Varicose eczema is caused when pressure increases in the veins running under the skin and in the deep muscles of the legs. This raised pressure is due to leaky valves in the veins. When the valves are not working well, it is difficult for the blood to flow back up the legs against gravity. So they are more full of blood than they should be, which means the pressure inside them is higher. The increased pressure in the veins makes them leak. Fluid and blood cells leak out of the veins and under the skin. This sets off a reaction under the skin. The effect of this is inflammation of the skin and then eczema. Over time the affected skin becomes harder and discoloured. Because skin with eczema is scaly and can become broken, it is more prone to developing ulcers.
Varicose eczema can also occur after a blood clot (thrombosis) forms in the deep veins.
What is the treatment for varicose eczema?
- Try to avoid injuring the skin (for example, against furniture).
- Put your legs up on a pouffe or footstool when sitting. (When your legs are up, gravity helps the blood flow back up the legs.)
- Keep active and go for regular walks. (When the muscles in your leg are active, they help push the blood in the veins back up the legs.)
- Avoid standing still for long periods of time. (In this position there is more pressure on the veins in the legs. The muscles are not squeezing the veins, as they do when you are walking.)
- Make sure the skin does not become too dry by using regular moisturising creams (emollients). See separate leaflet called Emollients (Moisturisers) for Eczema for more details.
Steroid applied to the skin
If the skin becomes very inflamed, your doctor may prescribe a topical steroid (steroid creams or ointments applied to the skin). Topical steroids work by reducing inflammation in the skin. The steroid is applied as an ointment rather than a cream if the skin is very dry. A moderate-strength steroid is usually prescribed unless the skin is very inflamed, in which case a very strong ointment may be needed.
Topical steroids are usually applied once a day (sometimes twice a day - your doctor will advise). Rub a small amount thinly and evenly just on to areas of skin which are inflamed. (This is in contrast to emollients described earlier which are applied generously.)
To work out how much you should use for each dose, squeeze out some ointment from the tube on to the end of an adult finger - from the tip of the finger to the first crease. This is called a fingertip unit. One fingertip unit is enough to treat an area of skin twice the size of the flat of an adult's hand with the fingers together. Gently rub the cream or ointment into the skin until it has disappeared. Then wash your hands.
Compression stockings are also known as compression hosiery. The stockings work by applying pressure from outside the veins. This helps squeeze the blood in the veins back up the legs. This then makes the pressure inside the veins less. In turn this prevents leakage of blood into the surrounding tissues.
Before compression stockings are advised you will need to have a test to check that the circulation through the arteries of your legs is normal. This is usually done by the practice nurse, with a handheld machine called a Doppler. This measures the pressure in your arteries.
Compression stockings come in light, medium or strong material (class 1, 2 or 3) and are worn below the knee. Most people can tolerate class 2. If class 2 is too uncomfortable or difficult, class 1 is prescribed. If class 2 stockings do not work it may be necessary to try class 3, although many people find these difficult to wear for any length of time. These can be prescribed by your doctor, and obtained at the chemist. People often do not like wearing these stockings, because they are uncomfortable, or difficult to put on, or don't look very nice. But they really help your circulation, and can prevent serious problems such as ulcers.
Further tips on support stockings
- They are available in different colours, so do ask for the one that suits you best. That way, you are more likely to use them.
- They should be removed at bedtime and put on first thing in the morning. It is important to put them on before your legs start to swell in the mornings.
- There are open or closed toe options. Open toe stockings may be useful if:
- You have painful toes due to arthritis or infection.
- You have large feet.
- You want to wear socks over your support stockings.
- You prefer them.
- Stockings should be replaced every 3-6 months. Each time you should be measured again, just in case the size needs to be changed.
- You should always have at least two pairs prescribed so that one pair can be washed and dried while the other is worn.
- Do not tumble dry support stockings, as this may damage the elastic.
- They can be made to measure if none of the standard sizes fit you. This can still be done with a prescription.
- Support stocking applicator aids are available if you are unable to get them on. You can discuss this with your pharmacist or nurse.
What if treatment doesn't work?
If your condition does not seem to be responding to treatment, your doctor may consider patch testing to check if you have developed contact dermatitis. This is a sensitivity to any of the creams, ointments or dressings you have applied to the skin. Patch testing involves putting various chemicals in patches on to the skin to see whether a reaction develops. This is usually done by a skin specialist (dermatologist).
You may also be referred to a dermatologist for more specialised advice about your skin problem.
Lack of progress sometimes means that infection has set in. Antibiotic tablets, such as flucloxacillin, may be needed if this is the case.
You may need to be referred to a surgeon who specialises in arteries and veins (a vascular surgeon.) You may require an operation if:
- Your varicose eczema will only get better if underlying varicose veins are treated.
- You have a leg ulcer which is not responding to medical treatment.
- You have a blockage in the arteries of the leg.
Herbal preparations applied to the skin have been known to cause allergic reactions and are best avoided. It may be that a herbal treatment made from horse chestnut seed extract and taken by mouth can help. However, more tests are needed on this to decide on the best dose to take. It cannot be prescribed by your doctor, but may be available from health food shops, etc.
Further help & information
Dr Laurence Knott
Dr Mary Harding
Prof Cathy Jackson