By Gary M. White, MD
A deep-seated, tender, irregular red plaque on the inner ankle.
Lipodermatosclerosis is a thickening and inflammation of the skin about the medial lower leg. It results from chronic venous hypertension, usually in the setting of venous insufficiency.
One or both lower legs are affected. In the acute phase, a tender, inflamed, plaque occurs on the medial ankle. Over time, the skin becomes indurated and hardened. The demarcation between the edematous skin above and the indurated and bound-down skin below is relatively distinct. A drop-off is often noted. The shape of the leg is that of an inverted bottle. Areas of atrophy blanche are common. Varicose veins and an ankle flare are typical. A brownish color along with hemosiderin deposition is often seen. Pain is often a prominent feature. Ulceration may occur.
The diagnosis is usually a clinical one. One may consider a biopsy to verify the diagnosis, but healing will be slow and difficult. It should be avoided if possible. * Occasionally, this condition is confused with Vilanova disease.
As this disease seems to be caused by venous insufficiency, all the usual approaches to controlling venous insufficiency should be followed including the use of support hose and weight loss if appropriate. (For a related condition and treatment advice, see stasis dermatitis.) Initially, one can use an Unna Boot for 6 weeks followed by switching to middle strength support hose (30-40 mm Hg). I have generally found that if patients are religious about the use of support hose, the condition dramatically improves over 2-4 months.
Occasionally, patients have a hard time compressing the leg with OTC products on their own due to pain. Referral to a lymphedema clinic or specialist in compression options can be helpful. Some patients may benefit from a referral to a vein specialist for workup of their venous insufficiency.
Pentoxifylline (Trental) is FDA approved for intermittent classification due to chronic occlusive arterial disease presumably by decreasing blood viscosity. The main side effect is nausea which is much less common with the extended release tablets. The standard approved dose is 400 mg po TID with meals. Anecdotally, pentoxifylline it has been helpful in patients with lipodermatosclerosis.
Some prescribe a potent topical steroid occluded initially if there is a significant inflammatory component.
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