What To Do About Venous Stasis Disease Siobhan Ryan, MD, FRCPC; Gary Sibbald, MD, FRCPC; and Patricia Couts, RN As presented at the 16th Annual Symposium of Advanced Wound Care, Las Vegas (April 29, 2003) hronic lower limb edema is a common bilateral, but in the early, acute stages it may Cproblem due to congestive heart failure, present as a unilateral, reddish to purple, low albumin, or venous stasis. Often this swollen lower limb. However, it is unrespon- edema is caused by venous stasis or chronic sive to antibiotics, and would not be associat- venous insufficiency, and the etiology is vari- ed with any systemic symptoms. Venous stasis able (Table 1). Chronic venous insufficiency presents clin- Table 1 ically as a spectrum of features (Figure 1). Causes of venous diseases Lipodermatosclerosis, cellulitis, venous Valvular insufficiency stasis dermatitis, and acute contact dermatitis • Superficial, perforating, or deep veins on the lower limb may, at times, be difficult to • Atrioventricular shunts differentiate. Lipodermatosclerosis is usually Calf muscle pump failure Post-surgical • Varicose vein surgery Margaret’s case • Vein harvesting Trauma Margaret, 57, has a • Crush injury long history of swollen • Shotgun wound ankles that she initially • Radiation noticed with the first of her four pregnancies. Obstruction The degree of swelling • Acute (phlebitis or infection/cellulitis) has progressed over • Abdominal obstruction time and has been Post-phlebitic syndrome aggravated by prolonged standing at Obesity work. Over the last Medication year, she has noticed • Steroids, estrogens, calcium channel an itchy, reddish discolouration on the lower blockers part of both her legs. Lifestyle/occupation For a followup on Margaret, see page 88. Comorbid illness causing generalized edema 84 The Canadian Journal of Diagnosis / December 2003 Venous Stasis dermatitis and acute contact dermatitis would ent contact dermatitis might benefit from patch both be itchy. testing to determine However, patients if they have a known may describe a dis- contact allergy that comfort that is burn- may be contributing ing rather than itchy, to their disorder. which can make the Superficial diagnosis more diffi- thrombophlebitis is cult. often a difficult Topical products diagnostic chal- that contain irritants lenge. Clinically, the and potential aller- skin lesions should gens should be avoid- be somewhat linear ed in patients with and tender. The dif- venous stasis. ferential diagnosis Compounds contain- includes erythema ing lanolin, baci- nodosum, panniculi- tracin, neomycin, tis, and vasculitis. colophony, and per- Support stockings fumes are commonly can be used in associated with con- patients with super- tact dermatitis in ficial, but not deep, patients with venous thrombophlebitis, stasis disease. and exercise is not Patients with persist- contraindicated. Non-steroidal anti- inflammatory med- Dilated saphenous vein Superficial varicosities and varicose veins Dr. Ryan is a staff dermatologist, Wound Healing Clinic, Sunnybrook & Women’s College Health Sciences Centre, Toronto, Ontario. Lower leg edema Dr. Sibbald is director, continuing medical education, department of medicine, University of Toronto, and director Pigmentary changes of the distal leg Dermatology Day Care and Wound Healing Clinic, Sunnybrook & Women’s College Health Sciences Centre, Woody fibrosis Toronto, Ontario. Ms. Couts is a registered nurse, a wound care specialist, and Lipodermatosclerosis a clinical trials coordinator, Mississauga, Ontario. Figure 1. Progression of chronic venous insufficiency. The Canadian Journal of Diagnosis / December 2003 85 Venous Stasis Table 2 Complications of venous stasis disease Diagnosis Presentation Treatment Comments Pitting edema Dull ache at end of day; Compression bandaging, Non-elastic stockings or may be asymmetric support stockings, ambulation, bandages may initially exercise, improve calf be preferred, as they muscle pump are less likely to cause pain at rest Superficial Pain and tenderness along Compression, ambulation, Risk of associated, phlebitis affected vein; usually NSAID therapy underlying DVT is low, saphenous especially if affected area is below the knee Deep phlebitis Acute, red, tender, swollen ASA, unfractionated heparin, Suspect a DVT in patient (DVT) calf—almost too painful warfarin, LMWH, bed rest with a sudden increase in to touch; Doppler necessary calf pain, with risk factors, to confirm diagnosis such as immobilization, recent surgey, oral contraceptives, etc. Acute Difffuse, purple-red, swollen Compression bandaging, Usually bilateral, though lipodermato- leg resembling cellulitis; support stockings, NSAIDs, may be more prominent sclerosis aching and tenderness are pentoxifylline on one leg; compression common therapy essential Chronic Diffuse, brown, sclerotic Same as with acute form, but Support stockings may lipodermato- pigmentation with widespread with topical steroids and have to be custom-made sclerosis chronic pain lubricants to accomodate for leg shape Wound infection Change in pain character Topical antimicrobial agents Maintain bacterial associated with other clinical and oral antibiotics, as indicated balance and watch for signs of infection increase in pain, size, exudates, odour, or granulation tissue as signs of infection Cellulitis Diffuse, bright red, hot leg; IV oral antibiotics; antibiotics Venous ulcers may make usually unilaterally associated needed for severe episodes individuals more prone to with tenderness and fever or with low host resistance cellulitis Atrophie blanche Pain, stellate, white, scar-like NSAIDs, other analgesics May be seen with scars areas associated with pain at of healed ulcers, or may be rest and standing an independent clinical feature Acute contact Itching, burning, red areas Remove the allergen; apply Lanolin, colophony, dermatitis on leg corresponding to area topical steroids perfumes, and neomycin of use of topical products are some of the more likely agents involved Cutaneous 2/3 of venous ulcers are Compression, moisture balance, Choice of compression ulcer/wound painful, with significant bacterial balance, and must be achievable, impact on quality of life debridement wearable, and affordable DVT: Deep venous thrombosis ASA: Acetylsalicylic acid NSAID: Non-steroidal anti-inflammatory drug IV: Intravenous LMWH: Low-molecular-weight heparin 86 The Canadian Journal of Diagnosis / December 2003 Venous Stasis ications are helpful, though introduction of stasis and then attempting to reverse it; and cyclooxygenase-2 2. Controlling the inhibitors remains venous insufficien- controversial. The cy with support association of an stockings (Table 3). underlying deep vein thrombosis with Once a patient superficial throm- has been diagnosed bophlebitis below the with chronic venous knee is felt to be insufficiency, sup- unlikely. port stockings are A summary of the recommended and complications of encouraged to be venous stasis disease continued as long as is provided in Table 2. possible. At times, other disease How is venous processes develop insufficiency that prevent the use managed? of support stock- ings, such as arterial Managing the patient insufficiency of the with chronic venous lower limbs. If there insufficiency involves is clinical evidence two steps: to suggest peripheral 1. Establishing the arterial insufficien- cause of the venous cy of the lower legs, then an arterial Table 3 Doppler ultrasound Classification of support stockings would be helpful to obtain an ankle- Class Strength (mmHg) Use brachial index I 20-30 Varicose veins, mild edema (ABI). However, in II 30-40 Moderate edema, severe varicose veins, moderate venous insuffiency the absence of a III 40-50 Chronic venous insufficiency contraindication, IV > 60 Elephantiasis, irreversible support stockings lymphedema should be part of Dress 15-22 When class I is not tolerated for the long-term plan support varicose veins and mild edema of care. The Canadian Journal of Diagnosis / December 2003 87 Venous Stasis Frequently Asked Questions Barriers exist that 1. Is it appropriate to order high may prevent the patient A followup on Margaret compression bandages for a from wearing support patient with acute The patient has venous stasis dermatitis and lipodermatosclerosis and poor stockings (Table 4). no other medical disorder. Support stockings peripheral pulses without first Often, taking the time of medium strength (20-30 mmHg) are obtaining an ABI? ordered, as well as a mild topical steroid to to review these barriers be applied to the dermatitic areas at night. A Prior to ordering high- with the patient, and followup appointment is made for six weeks compression bandaging, the peripheral vascular status should attempting to find a to determine if Margaret is able to wear her stockings, and to review the importance of be assessed. solution will help the long-term use of support stockings to Non-invasive techniques include patient adhere to the prevent progression of her venous stasis obtaining an ABI, toe pressures, plan of long-term sup- disease. toe brachial index, ankle Doppler waveforms, or transcutaneous port stocking use. oxygen levels. More invasive investigations are not indicated for this purpose. 2. What is the treatment when an Table 4 acute allergic contact dermatitis Barriers to support stockings is a suspected cause of a flare of pre-existing venous stasis Barrier Solution dermatitis? Comorbid illness Choose a stocking that is easy to First, the suspected allergen must ® apply; use