Do you have a rash on your leg?

 I once had a woman come to me as a patient for an evaluation of a dark rash on the front of her right leg with mild swelling.  She says the rash always stays the same but the swelling is worse at the end of the day.  The key to her story is that she has almost no swelling when she wakes up in the morning.  She saw a dermatologist who prescribed some antifungal creams for this rash but it never cleared up.  She was very frustrated.  What was this rash?   

The official diagnosis was venous stasis dermatitis from venous insufficiency.  Well to break it down, this is a circulation issue.  Not the arteries.  She had good pulses in her feet (pedal pulses) so the arteries were bringing the oxygenated blood to the feet.  This is the most important part of foot health – the arterial circulation.  You must have good arterial circulation to literally keep your feet but that is another topic.  

This patient had insufficient venous circulation.  It is easier for the arteries to bring blood down to the feet with the help of gravity but the veins have to bring the deoxygenated blood back up to the heart and lungs against gravity.  So to help this venous blood to travel up, there are valves in the veins that push this blood up.  Over time, sometimes these valves get damaged, become insufficient and cannot do a good job at this so the venous blood pools in the legs and the legs increasingly swell.  Superficial and deep varicose veins develop and the venous purplish blood deposits some of its contents called hemosiderin deposits.  

This is what is responsible for the “rash” on this patient’s legs.  This is called venous stasis dermatitis.  So that is why the antifungal did not work as it is not a fungus nor did the steroids work as it doesn’t help the venous blood travel up the leg.  If this persists, venousstasis ulceration can develop with the increased swelling as the fluid has nowhere to go but out and the skin breaks opens.  

Increased age, smoking, genetics, obesity, trauma and pregnancy are all risk factors of venous insufficiency.  Compression stockings (support hose), pneumatic compression devices, weight loss, elevation and exercise can all help manage this condition.  Wound care is needed for an open wound (ulceration) and sometimes if severe enough, referral to a vascular specialist is necessary.