Chronic venous insufficiency occurs when blood does not efficiently drain from the legs back to the heart. Usually, this is the result of damage to the valves inside the veins. This damage may occur with age, immobility, obesity, prolonged standing or after a deep vein thrombosis. It is often associated with varicose veins.
The valves are responsible for ensuring blood flows in one direction as the leg muscles contract and squeeze the veins. When the valves are damaged, the pumping effect of the leg muscles becomes less effective in draining blood towards the heart. Blood pools in the veins of the legs, causing venous hypertension.
Chronic pooling of blood in the legs leads to skin changes. The area between the top of the foot and the bottom of the calf muscle is the area most affected by these changes. This is known as the gaiter area.
Haemosiderin staining is a red/brown discolouration caused by haemoglobin leaking into the skin.
Venous eczema (or varicose eczema) is dry, itchy, flaky, scaly, red, cracked skin. These eczema-like changes are caused by a chronic inflammatory response in the skin.
Lipodermatosclerosis is hardening and tightening of the skin and tissue beneath the skin. Chronic inflammation causes the subcutaneous tissue to become fibrotic (turning to scar tissue). Inflammation of the subcutaneous fat is called panniculitis. The narrowing of the lower legs causes the typical “inverted champagne bottle” appearance.
Atrophie blanche refers to patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation.
As well as the skin changes above, chronic venous insufficiency can lead to:
- Cellulitis
- Poor healing after injury
- Skin ulcers
- Pain
TOM TIP: Chronic venous changes are very common in older patients. It is very easy to find patients with these skin changes to use in OSCE examinations, so it is worth getting familiar with their appearance and confidently presenting your examination findings. These changes are often misdiagnosed as cellulitis, and patients are given a course of antibiotics. The broken skin does leave patients prone to skin infections, so this does need to be considered, although keep in mind that “bilateral cellulitis” is quite unusual, and chronic skin changes related to venous insufficiency will not resolve with antibiotics.
Management
Management involves:
- Keeping the skin healthy
- Improving venous drainage to the legs
- Managing complications
The skin is kept healthy by:
- Monitoring skin health and avoiding skin damage
- Regular use of emollients (e.g., diprobase, oilatum, cetraben and doublebase)
- Topical steroids to treat flares of venous eczema
- Very potent topical steroids to treat flares of lipodermatosclerosis
Improving venous drainage to the legs involves:
- Weight loss if obese
- Keeping active
- Keeping the legs elevated when resting
- Compression stockings (exclude arterial disease first with an ankle-brachial pressure index)
Management of complications involves:
- Antibiotics for infection
- Analgesia for pain
- Wound care for ulceration
Last updated May 2021
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