A red, scaly rash with pitting edema on the lower leg of an elderly person.
A red, scaly rash with pitting edema on the lower leg of an elderly person.
Stasis dermatitis (SD) represents an inflammatory rash of the lower legs in the setting of leg swelling and poor circulation.
The skin about the inner ankle is red and scaly. These changes may extend up the lower leg to the knee. Edema is always present and may be severe. Varicosities may be seen about the lower leg. An ankle flare may be present. Over time, the skin may take on a brownish discoloration due to hemosiderin deposition. In chronic and/or severe cases, ulceration may occur.
Lower extremity cellulitis is more likely if there is asymmetry (one sided), tachycardia, leukocytosis (i.e. WBC > 10,000), tachycardia (pulse > 90) and age > 70 .
Stemmer's test results in either a positive or negative sign for lymphedema. To perform it, try to pinch and lift a skinfold at the base of the second toe or middle finger. If you can pinch and lift the skin, Stemmer's sign is negative. If you can't, the sign is positive. False positives never occur. On the other hand, a negative test doesn't rule out lymphedema.
Daily use of support hose to prevent swelling is key. Instruct the patient to wear them whenever s/he is not in the shower and not in bed. Buy just one pair initially to see if they fit and are relatively comfortable. Many patients complain of heat and pain during use. A lot of support and encouragement is needed as patients usually are not too fond of wearing support hose but they are key!!
Before starting compression therapy, the following should be excluded as they are contraindications:
Complications to compression therapy include:
A medium-to-high-potency topical steroid ointment to calm any inflammatory component is indicated. Sometimes applying it at night is helpful so as not to grease up the hose during the day. On the other hand, applying a grease to the legs beforehand can allow the hose to slide on much easier.
Some recommend strengthening the calf muscles to reduce edema. The may be done with standing heel rises (e.g. 20-30) performed several times a day or full-stride walking or stair climbing.
Use Vaseline, Aquaphor or moisturizing cream ongoing to prevent future outbreaks.
If there are any wounds or ulcer, the dressing/bandage should be applied under the hose.
For patient's with chronic lymphedema and recurrent cellulitis, the use of an advanced pneumatic compression device may be beneficial.
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