Stasis dermatitis

Background

Stasis dermatitis is a chronic inflammatory skin condition caused by venous insufficiency, typically affecting the lower legs. It results from sustained venous hypertension that leads to capillary leakage, inflammation, and skin breakdown. It is commonly seen in older adults or individuals with a history of varicose veins, obesity, immobility, or deep vein thrombosis (DVT). Though not an emergency itself, patients often present to the ED for evaluation of suspected cellulitis, ulceration, or non-healing wounds, making differentiation critical.

Clinical Features

• Usually bilateral (but can be asymmetric)
• Skin findings:
  • Erythema, hyperpigmentation (hemosiderin deposition)
  • Scaling, weeping, or crusting
  • Lichenification or thickening over time
  • Pruritus is common
• Associated signs:
  • Pitting edema
  • Varicosities
  • Chronic atrophic or ulcerated skin
  • Lipodermatosclerosis (woody induration in chronic cases)

Differential Diagnosis

• Cellulitis (often unilateral, systemic symptoms present)
• Contact dermatitis
• Tinea corporis or tinea incognito
• Autoimmune vasculitis
• Lymphedema
• Erythema nodosum
• Necrobiosis lipoidica diabeticorum
• Cutaneous lymphoma (rare but important mimic)

Evaluation

Workup

• Usually a clinical diagnosis, but consider:
• Ultrasound of lower extremities if DVT is suspected
• Wund culture if there is ulceration with purulence
• CBC, CRP if systemic signs are present and infection is suspected
• Blood glucose or A1C in patients with ulceration or delayed wound healing

Diagnosis

• Chronic bilateral lower extremity erythema, scaling, and edema in setting of known or suspected venous insufficiency
• Absence of systemic signs (e.g., fever, leukocytosis) helps rule out cellulitis
• Skin biopsy is rarely needed

Management

• Compression therapy (unless contraindicated, e.g., ABI < 0.8)
• Topical corticosteroids (low- to mid-potency for inflammation and pruritus)
• Emollients to restore barrier function
• Leg elevation
• Avoidance of trauma or scratching
• If secondary infection suspected:
  • Topical antibiotics (e.g., mupirocin) for localized impetiginization
  • Systemic antibiotics only if signs of infection are present
• Educate patient on chronicity and importance of vascular follow-up

Disposition

Discharge with outpatient follow-up for:

• Uncomplicated stasis dermatitis
• Chronic ulcers without systemic signs
• Education on leg elevation, compression, and wound care

Admit or refer if:

• Cellulitis or soft tissue infection is present and systemic signs (e.g., fever, leukocytosis)
• Non-healing ulcer with suspicion for osteomyelitis or diabetic foot infection
• Concern for DVT (consider compression US if available)
• Severe pain, rapid progression, or suspicion of necrotizing infection

Ensure wound care, vascular, or dermatology follow-up if:

• Chronic ulcers
• Recurrent dermatitis
• Need for compression therapy fitting