Varicose eczema

Varicose eczema is a long-term skin condition that affects the lower legs and is common in people with varicose veins.

It is also known as venous eczema, gravitational eczema and stasis eczema.

Signs and symptoms

Like all types of eczema, the affected skin becomes:

• itchy
• red and swollen
• dry and flaky 
• scaly or crusty

There may be periods when these symptoms improve and periods when they become more severe.

Your legs may become swollen, especially towards the end of the day or after long periods of standing. Varicose veins (swollen and enlarged veins) are often visible on the legs.

Some people also have other symptoms, such as:

• brown discolouration of the skin
• red, tender and tight skin that can eventually become hardened (lipodermatosclerosis)
• small, white scars (atrophie blanche)
• pain
• eczema affecting other parts of the body

Left untreated, leg ulcers can develop. These are long-lasting wounds that form where the skin has become damaged.

When to seek medical advice

See your GP if you have symptoms of varicose eczema. They will often be able to make a diagnosis simply by looking at the skin.

Read more about diagnosing varicose eczema.

What causes varicose eczema? 

Varicose eczema is caused by increased pressure in the leg veins.

When the small valves in the veins stop working properly, it's difficult for blood to be pushed against gravity and it can leak backwards.

This increases the pressure in the veins, which can cause fluid to leak into the surrounding tissue. It is thought that varicose eczema may develop as a result of the immune system reacting to this fluid.

Varicose eczema is more common in people with varicose veins, as these are also often a sign that the leg veins aren’t working properly.

Read more about the causes of varicose eczema.

How varicose eczema is treated

Varicose eczema tends to be a long-term problem. However, treatments are available to help keep it under control.

For most people, treatment involves a combination of:

• self-help measures – including ways to improve your circulation, such as keeping active and frequently raising your legs
• emollients – moisturisers applied to the skin to stop it becoming dry)
• topical corticosteroids – ointments and creams applied to the skin to help treat the eczema and relieve symptoms
• compression stockings – specially designed stockings, usually worn every day, that steadily squeeze your legs and help to improve your circulation

If these treatments don’t help, your GP may refer you to a dermatologist (skin specialist) in case there is another cause for your symptoms or if they are concerned you may also have a type of eczema called contact dermatitis.

If you also have varicose veins, you may be referred to a vascular specialist (a doctor or surgeon specialising in conditions affecting the blood vessels) who can talk to you about the treatment options for varicose veins.

Read more about treating varicose eczema.

Varicose eczema is usually caused by increased pressure in your leg veins.

Inside your veins there are valves that let the blood through in one direction and prevent it flowing backwards.

Sometimes, the walls of the veins can become stretched and lose their elasticity, causing the valves to become weakened. If the valves do not function properly, blood may leak backwards.

This increases the pressure in your veins, which may cause fluid to leak into surrounding tissues. It is thought that varicose eczema may develop as a result of your immune system reacting to these fluids in the tissues under your skin.

This increase in pressure can also cause blood to collect in your veins, which become swollen and enlarged (varicose veins).

Who's most at risk?

It is not fully understood why the walls of the veins stretch and the valves weaken. Some people develop the condition for no obvious reason, although there are certain factors that increase the chances of this happening, including:

• gender – varicose eczema is more common in women
• obesity – this can increase the pressure in your leg veins
• pregnancy – this can also increase the pressure in your leg veins
• not being able to move for a long period of time – this can affect the circulation in your leg veins
• having previously had deep vein thrombosis (DVT) – blood clots that develop in leg veins, which can damage the valves in your veins
• increasing age – people generally find it harder to move about as they get older, which can affect their circulation

See your GP if you have symptoms of varicose eczema. They can usually make a diagnosis by simply looking at the affected areas.

Your GP will also ask you questions to determine whether you have a problem with the flow of blood in your leg veins, as this is the main cause of varicose eczema.

To help make a diagnosis, your GP may want to know if you have a history of:

• varicose veins – swollen and enlarged veins
• deep vein thrombosis (DVT) – a blood clot in one of the deep veins of your legs
• leg ulcers – areas of damaged skin that take several weeks to heal
• cellulitis – an infection of the deeper layers of the skin and underlying tissue
• surgery or injury to your legs

Your GP may also check the pulse in your feet and they may carry out an ankle brachial pressure index (ABPI) test to see if compression stockings are suitable for you. See the section on treating varicose eczema for more information about these.

The ABPI test involves comparing blood pressure readings taken from your ankles and upper arms. A significant difference in the readings suggests a problem with the flow of blood in your arteries – in which case, compression stockings may not be safe to use.

Referral to a specialist

You may be referred to a specialist in a local hospital for further tests. This might be a vascular specialist (a doctor or surgeon specialising in conditions affecting the blood vessels) or a dermatologist (a specialist in skin conditions) if:

• you have varicose veins and changes to your skin, such as varicose eczema, lipodermatosclerosis (hard, tightened skin) or a history of leg ulcers
• you have very poor blood flow in the blood vessels in your legs 
• your symptoms don't get better, despite treatment 
• it is possible that you may have contact dermatitis

Treatment for varicose eczema aims to improve the condition of your skin, treat your symptoms and help improve your circulation (blood flow).

For many people, this will involve long-term treatment with a combination of:

• emollients (moisturisers) 
• topical corticosteroids
• compression stockings

There are also some self-help techniques that you can try. These treatment options are described in more detail below.

Lipodermatosclerosis (hardened, tight skin) is treated in a similar way to varicose eczema. If you have a venous leg ulcer, you can also read about treating venous leg ulcers.

Self-help

There are some steps you can take to reduce the symptoms of varicose eczema and help prevent further problems, such as:

• try to avoid injuring your skin – injuries to your skin could lead to an ulcer developing
• raise your legs when you are resting – for example, by propping up your feet on some pillows (ideally so that they are above the level of your heart), as this can help reduce swelling 
• keep physically active – this will improve your circulation and help you maintain a healthy weight

Fluid can build up in the lower legs if you sit or stand for too long, so it is important to keep moving. Walking will get your muscles working and help to push the blood through the veins to your heart.

The National Eczema Society also recommends regularly flexing your feet and rising up onto your toes or bending down at the knees.

Emollients

Emollients are moisturising treatments applied directly to the skin to reduce water loss and cover it with a protective film. They are often used to help manage dry or scaly skin conditions such as eczema.

Choice of emollient

A number of different emollients are available. Some can be bought over the counter without a prescription, but if you have varicose eczema it may be helpful to ask your GP to recommend a suitable product.

You may need to try several different emollients to find one that works for you. You may also be prescribed a mixture of emollients, for example:

• an ointment for very dry skin 
• a cream or lotion for less dry skin
• an emollient to use instead of soap 
• an emollient to add to bath water or use in the shower

The difference between lotions, creams and ointments is the amount of oil that they contain. Ointments contain the most oil, so they can be quite greasy, but are the most effective at keeping moisture in the skin. Lotions contain the least amount of oil, so are not greasy, but can be less effective. Creams are somewhere in between.

How to use emollients

If you have varicose eczema, you should use an emollient at least twice a day, even if you do not have any symptoms.

To apply the emollient:

• use a large amount – you should aim to cover all of the skin on your lower leg, not just the obviously affected areas
• don't rub it in – instead, smooth it into the skin in the same direction that the hair grows
• apply every 2 to 3 hours for very dry skin 
• after a bath or shower, gently dry the skin, then immediately apply the emollient while the skin is still moist 
• do not share emollients with other people

It is very important to keep using emollients during a flare-up of varicose eczema, because this is when the skin needs the most moisture. Apply emollients frequently and in generous amounts during a flare-up.

Side effects

It’s unusual for emollients to cause side effects, but they can occasionally cause a rash, and greasy emollients may sometimes cause folliculitis (inflammation of the hair follicles). If you experience any side effects from your emollient, speak to your GP, who can prescribe an alternative product.

Emollients added to bath water can make your bath very slippery, so take care getting in and out of the bath.  

Topical corticosteroids

If your skin is inflamed from a flare-up of varicose eczema, your GP may prescribe a topical corticosteroid (corticosteroid medication that is applied directly to your skin in the form of a cream or ointment) to quickly reduce the inflammation. They are also commonly known as topical steroids.

Different strength topical corticosteroids can be prescribed, depending on the severity of your varicose eczema. If you have flare-ups of lipodermatosclerosis, you may need a very strong topical corticosteroid.

How to use topical corticosteroids

When using corticosteroids, only apply the treatment to the affected areas. Your doctor can advise you on how much to apply and how often. You can also check the advice in the patient information leaflet that comes with your medication.

Most people only have to apply a topical corticosteroid once a day. When applying the medication, you should:

• apply your emollient first and wait around 30 minutes before applying the topical corticosteroid (until the emollient has soaked into your skin)
• apply it only to the affected area
• use the topical corticosteroid for 7 to 14 days and continue to apply the treatment for 48 hours after the flare-up has cleared

If your varicose eczema is moderate to severe, you may need to apply topical corticosteroids both between flare-ups and during them.

If you need to use topical corticosteroids on a long-term basis, you should apply them less frequently. Your GP will advise you on how often you should be applying them.

You should also speak to your GP if you have been using a topical corticosteroid and your symptoms have not improved.

Side effects

Topical corticosteroids may cause a mild and short-lived burning or stinging sensation as you apply them, particularly if using a cream.

Generally, using a strong topical corticosteroid for prolonged periods will increase your risk of getting more serious side effects, such as thinning of the skin. Your doctor will advise you as to the strength of the medication you require and when you should use it.

Compression stockings

Medical compression stockings are specially designed to steadily squeeze your legs to help improve your circulation. They are tightest at the ankle and get gradually looser as they go further up your leg. This encourages blood to flow upwards towards your heart.

Medical compression stockings are used to treat varicose eczema and lipodermatosclerosis by improving the flow of blood through your leg veins and reducing the pressure in the veins.

Choice of compression stockings

Compression stockings are available in a variety of different sizes and pressures. They are also available in:

• different colours
• different lengths – some come up to the knee and others also cover the thigh (you should only need knee-high stockings for varicose eczema)
• different foot styles – some cover the whole foot and some stop before the toes

Support stockings or tights that lightly compress the legs can be bought from pharmacies. Compression stockings that compress the legs more are available on prescription and will require you to be measured by a nurse first.

In some cases, if you find it difficult to put on your stockings, you may be advised to use a tubular bandage instead.

Wearing compression stockings

You will usually need to put your compression stockings on as soon as you get up in the morning and take them off when you go to bed. Wearing compression stockings can be uncomfortable, particularly during hot weather, but it is important to wear them correctly to get the most benefit from them.

Pull them all the way up so that the correct level of compression is applied to each part of your leg. Do not let the stocking roll down, or it may dig into your skin in a tight band around your leg. Speak to your GP if the stockings are uncomfortable, they do not seem to fit, or you have difficulty putting them on. It may be possible to get custom-made stockings that will fit you exactly.

Take care when putting compression stockings on and taking them off, as this can damage fragile skin. If you have a leg ulcer, it ideally needs to heal before you start wearing compression stockings.  

Caring for compression stockings

Compression stockings usually have to be replaced every 3 to 6 months. Speak to your GP if your stockings become damaged, as they may no longer be effective. 
 
You should be prescribed 2 stockings (or 2 sets of stockings if you are wearing 1 on each leg) so that 1 stocking can be worn while the other is being washed and dried. Compression stockings should be hand-washed in warm water and dried away from direct heat.

Treating varicose veins

If you have varicose veins, as well as varicose eczema, treating these may sometimes be helpful.

If your GP thinks treatment may be beneficial, they can refer you to a vascular surgeon, who can arrange for an ultrasound scan of your leg to find the faulty blood vessels. Treatment of your varicose veins can then be planned.

There are a number of treatments available that can improve the symptoms and appearance of varicose veins, including:

• endothermal ablation – where energy from either high-frequency radio waves or lasers is used to seal the affected veins
• sclerotherapy – where a special foam is injected into your veins to seal them
• ligation and stripping – where affected veins are tied off and surgically removed

These procedures are usually performed in the day surgery department of a hospital.

Read more about treating varicose veins.