Varicose eczema is a skin condition that mainly occurs in the elderly. It initially causes your skin on the lower legs to become pale red, and then darker red, often becoming stained brown. With varicose eczema the skin on your lower legs also gets slightly thicker and bumpy. It may be very painful but there may be no pain. Itchiness is also variable from mild to severe. Because your skin is red with varicose eczema, it is often mistaken for an infection. The treatment is to keep your legs up when you're sitting down, to stay active and to apply moisturisers. Occasionally steroid ointments are used, which are prescribed by a doctor.
What is varicose eczema?
This is the term used for skin changes that happen when the pressure in the veins of the legs increases. You may also hear it called gravitational eczema, stasis eczema or venous eczema.
This is a photo of varicose eczema in an elderly man. It's an example of long-standing varicose eczema, as seen by the thickened, dark-stained skin:
Image featured here with full consent from patient for use by Patient.info
Varicose eczema symptoms
- The skin looks red and can be slightly shiny (which is why some people mistake varicose eczema for an infection).
- The skin should feel cool to the touch, not warm.
- The skin gets flaky and scaly.
- The skin may also look 'rusty' or brown in colour.
- The skin, particularly the skin around your ankle, may feel hard or tight.
- You can get little raised bumpy 'blisters' in the skin. Sometimes these are hard; other times they might leak a drop of clear fluid if you press them.
- Pain and itchiness are variable, ranging from absent to severe.
- It can feel like your legs are warm, although they are not warm to the touch.
- Generally it all starts in the skin around the inside of your calf, above your ankle.
- Some skin may 'break down' into an ulcer. See the separate leaflet called Venous Leg Ulcers for more information on this condition. If the ulcer is small and heals up, it can leave a star-shaped white mark.
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 (deep vein thrombosis - a DVT).
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.
Varicose eczema treatment
- The most important thing is to put your legs up as high as possible when sitting. Most pouffes or footstools just aren't high enough: it's best to have your feet as high as your hips, or even a bit higher! (When your legs are up, gravity helps the blood flow back up the legs.)
- Try to avoid injuring the skin (for example, against furniture).
- Keep active and go for regular walks. (When the muscles in your legs 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 the separate leaflet called Moisturisers (Emollients) 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 the standard sizes don't 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 reading and references
Venous Eczema; DermNet NZ
Venous eczema and lipodermatosclerosis; NICE CKS, May 2107 (UK access only)
Nazarko L; Diagnosis and treatment of venous eczema. Br J Community Nurs. 2009 May14(5):188-94.
Raju S, Hollis K, Neglen P; Use of compression stockings in chronic venous disease: patient compliance and efficacy. Ann Vasc Surg. 2007 Nov21(6):790-5.
Compression stockings; NICE CKS, September 2012 (UK access only)
Pittler MH, Ernst E; Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012 Nov 1411:CD003230. doi: 10.1002/14651858.CD003230.pub4.