Cathy Thomas Hess, BSN, RN, CWOCN, is President and Director of Clinical Operations, Wound Care Strategies Inc (WCS), Harrisburg, Pennsylvania. WCS focuses on clinical operational, regulatory, and compliance/auditing aspects of skin and wound care in all healthcare settings. Please address correspondence to: Cathy Thomas Hess, BSN, RN, CWOCN, 4080 Deer Run Court, Suite 1114, Harrisburg, PA 17112; e-mail: firstname.lastname@example.org
Venous, or stasis, dermatitis is defined as erythema and scaling that can vary from subacute, acute, to chronic inflammation. It may be on the legs of patients with chronic venous insufficiency and must be differentiated from cellulitis, which is an acute infectious process that requires systemic antibiotics.
Stasis dermatitis may be related to changes in the skin from the chronic edema and congestion seen in venous insufficiency or may be due to contact with sensitizing products, including ointment bases and preservatives, such as wool alcohols (lanolins), parabens, propylene glycol, ethylene diamine, and cetyl stearyl alcohols; antibacterial agents that might cause problems can be sodium fusidate, gentamicin sulfate, and neomycin; additives in bandages to consider are ester gum resin, colophony (adhesives), and additives, which prevent rubber and elastic from perishing; medicated preparations may contain benzocaine, neomycin, antihistamine creams, and balsam of Peru; and over-the-counter preparations with fragrances and preservatives.
Inspection of the skin is crucial to the assessment. Watch for dry skin, with scaling, flakiness, or peeling of the superficial layer of the skin. Second to controlling edema, keeping the skin of the lower extremities from drying out is an important step in preventing the acute, subacute, and chronic conditions (Table 1).
Several allergen tests can detect whether the patient is allergic to a product. An open patch test is performed by placing the suspected allergen to the skin of the upper outer arm and leaving it uncovered. The product is applied twice daily for 2 days. Check the site twice a day. A use test is performed by placing the product on a site away from the original dermatitis. It is applied twice a day for at least 7 days to the outer arm or the skin of the antecubital fossa. The test is stopped and considered positive if a reaction occurs. Closed patch testing is performed by placing the product on the skin and covering it with an adhesive bandage, which is taken off in 24 hours for initial assessment.
Patients with venous insufficiency should be tested directly on the legs below the knees, as the skin tends to be more sensitive there with severe disease. They may react to products on the legs, but not on the arms. Patch tests are considered positive if intense itching and/or redness occurs.
When subacute inflammation occurs, suitable products include lubricated creams or lotions for dry skin or intermediate- to high-potency topical steroid creams or ointments. Treatment for acute inflammation includes wet compresses, intermediate- to high-potency topical steroids, and systemic antibiotics. Chronic inflammation can be treated with cool compresses, followed by intermediate- to high-potency topical steroid creams or ointments.
Ingredients that help moisturize venous dermatitis include aloe vera, allantoin, cetyl alcohol, stearyl alcohol, and vitamins A and E. Skin protectants include petrolatum, a semitransparent ointment; zinc oxide, a white paste or cream; and dimethicone, a silicone cream that can be transparent upon application and dries quickly.
Additional treatments include the following:
* Oral antibiotics are effective against staphylococci-for example, cephalexin is useful when cellulites are present. However, even with severe dermatitis, in the absence of cellulites, it does not require antibiotic therapy.
* Wet compresses of Burrow's solution, saline, or tepid water for 30 to 60 minutes several times per day. These compresses tend to suppress the inflammation, while softening the dry scaly skin. Discontinue use before excessive dryness occurs.
* Topical steroids, such as group II to V steroid creams, may be effective. Typically, ointments are used for moistening and creams are used for drying. Many creams, however, contain more preservatives than ointments, causing adverse reactions in some patients. Fluocinolone acetonide ointment 0.025% is an example of an intermediate potency topical steroid with no preservatives.
* Leg elevation is useful because most venous disease is accompanied by edema.
Source: Hess CT. Clinical Guide to Skin and Wound Care. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.