54
SKIN CARE TODAY
2015,Vol 1, No 1
discouraged due to the increasing
incidence of resistance (O’Meara et
al, 2014).
Patients with venous eczema
are prone to developing contact
or allergic dermatitis due to
hypersensitivity to a substance
applied to the skin, either in topical
medicaments and/or dressings.
Acute flares of eczema and failure
to respond to treatment are
indications to refer the patient for
patch testing, which will help to
ascertain any sensitivities.
There is little reliable evidence
relating venous eczema with
psychological morbidity. However,
there are published reports of
depression and poor quality of life
associated with chronic venous
disease, of which venous eczema
may be a component (Sanchez et
al, 2013). Assessment of quality
of life and mood is therefore
advised using an appropriate tool,
e.g. Dermatology Life Quality
Index (DLQI), Patient Health
Questionnaire (PHQ-9), Hospital
Anxiety and Depression Scale
(HAD Scale), Generalised Anxiety
Disorder Assessment (GAD-7)
tools. Referral to an appropriate
healthcare professional (GP,
dermatologist, psychologist) will
be necessary to address
psychological morbidity.
Holistic needs assessment
including quality of life is
an important aspect of care
provision for all patients with
skin conditions (Green, 2012; All
Party Parliamentary Group on Skin
[APPGS], 2013). Patients living
with venous eczema require such
support and guidance to enhance
self-efficacy skills and quality
of life.
FOCUS ON VENOUS ECZEMA
i
i
Sub-acute and chronic dry
eczema require emollients
i
Inflamed eczema requires
topical corticosteroids
i
Infected eczema requires topical/
systemic antibiotics (Primary
Care Dermatology Society
[PCDS], 2014).
Acute, wet, weeping inflamed
varicose eczema requires the
lower leg to be soaked for 20
minutes in a solution of potassium
permanganate 1:10,000 solution
(British National Formulary
[BNF], 2012). As a mild antiseptic
and drying agent, potassium
permanganate effectively treats
wet, eczematous skin conditions.
Treatment regimen should include:
i
Daily soaks can be continued
until dried exudate, crusts and
serous fluid are no longer evident
i
Cleansing of the skin and
moisturisation can be achieved
using an oil-in-water-based
cream or lotion
i
Moisturising the skin can
continue at least twice-daily.
Thereafter, progress to a
greasier-based emollient as the
skin becomes more dry and scaly
i
Any residual inflamed skin
can be treated with a mild-to-
moderate topical corticosteroid
i
Due to the vulnerability of
the skin in venous eczema,
topical corticosteroids should
be used intermittently, only
when inflammatory lesions
are present. Potent and very
potent topical corticosteroids
are usually avoided with venous
eczema, as there is a potential
for further thinning of the skin,
which will be prone to trauma
and ulceration.
Sub-acute and chronic
venous eczema, including
lipodermatosclerosis, respond well
to daily intensive emollient therapy.
Emollient soaks, moisturisation and
intermittent mild-to-moderately
potent topical corticosteroids (only
on inflammatory lesions) effectively
soothe itch and protect the skin.
Potent topical steroids can be
considered under specialist medical
supervision for lipodermatosclerosis
(NICE, 2012a).
Medicated paste bandages
have a place in the management
of chronic venous eczema where
occlusion is indicated and can be
used under compression hosiery,
if venous insufficiency exists.
Ichthammol paste bandages and
zinc paste bandages provide a moist
skin-healing environment and have
antipruritic and anti-inflammatory
properties (British National
Formulary [BNF], 2015).
Emollient wet wrap technique
is also useful in removing adherent
scale of venous eczema without
damaging the skin. The key is
to use a technique that does not
traumatise the underlying skin,
i.e. emollients and very gentle
debridement when scale and
hyperkeratosis are soft and moist.
Monofilament debridement pads
may facilitate this.
Managing complications
of venous eczema
Itch and pain are the most
commonly reported symptoms
of venous eczema. Itch results in
scratching, which can traumatise
the skin further. Complications
of this are:
i
Recurrent secondary infection
i
Ulceration
i
Contact dermatitis
i
Allergic dermatitis
i
Psychological morbidity
i
Poor quality of life.
Management of itch is as
important as management of pain
and eczema (Paul et al, 2011).
Emollients can effectively reduce
itch, so their importance should not
be underestimated. Antihistamines
have little effect in relieving
itch (Apfelbacher et al, 2013).
Psychosocial interventions for itch
management are also useful, such
as habit reversal, distraction and
behaviour modification (patting the
skin rather than scratching). Pain
can be relieved by oral analgesics.
Secondary infection will require
topical or systemic antibiotic
therapy. A skin swab should be
obtained and sent to microbiology
for culture and sensitivity, as long-
term systemic antibiotic therapy is
Increasing prevalence of
venous eczema occurs
with women, increasing
age and obesity in adults
with superficial venous
disease (Brown and Rossi,
2013).
