Lower Leg Lesions

Tortuous, dilated varicosities; multiple smaller caliber abnormal perforating vessels; and chronic brawny edema of chronic venous insufficiency (CVI) were seen on a 70-year-old man’s left leg (A). He reported that the edema and discoloration had worsened over the last 15 years. The brawny edema stopped just above the ankle, indicating that compression by the patient’s sock controlled the signs and symptoms of CVI.
Stellate dermal sclerotic changes that developed from old healed stasis ulcers were noted on the medial aspect of the foot (B). These hypopigmented changes, known as atrophie blanche, are typical of chronic CVI but may be seen in other conditions as well. The starlike porcelain-white scars also demonstrate peripheral telangiectasia and hyperpigmentation.

Venous stasis arises from incompetent venous valve function, which impedes venous flow to the heart. Predisposing factors for CVI are female sex, family history of the disease, pregnancy, and minor leg injury. A host of skin manifestations may be associated with CVI, including varicose veins, dependent edema, pigmentary changes that are secondary to hemosiderin staining from extravasated red blood cells and from postinflammatory hyperpigmentation, stasis dermatitis, atrophie blanche, ulceration, and lipodermatosclerosis (woody induration of the lower third of the affected leg in advanced CVI).

The mainstays of treatment are compression with stockings or a soft cast and leg elevation, especially when seated; surgical intervention may become necessary. A topical mid-potency corticosteroid ointment can be used to treat the acute dermatitis and emollients can be helpful for prevention.

In addition to compression stockings and leg elevation, this patient used triamcinolone ointment, 0.1%, for CVI-associated dermatitis. He was lost to follow-up.

(Case and photographs courtesy of Joe Monroe, PA-C.) 

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