In the store-and-forward teledermatology modality, there is a transfer of patient medical information electronically (including history and visual data) obtained in one location to a provider who is in another location. The construct of the TeleDermViewPoint column is such that cases are presented in a standardized teledermatology reader format reflective of an actual teledermatology report.
TELEDERMATOLOGY READER REPORT1
Presenting for diagnosis and therapeutic options.
History of present illness
A 68-year-old Caucasian male presents with chronically worsening pruritus of the lower legs that is intermittently accompanied by swelling and pain. The patient states that he first noticed skin changes in his bilateral lower extremities 2 years ago. Prior treatment: topical antifungals. Primary symptoms: itch. Significant laboratory findings: none. Medical history: diabetes mellitus type II, hypertension, and mild congestive heart failure with preserved ejection fraction as well as 40-pack-year smoking history.
IMAGE QUALITY ASSESSMENT
Satisfactory. One image was provided, showing only the lower left leg. The image reveals notable indentation suggestive of pitting edema, on hemosiderin-laden (reddish-brown discoloration) background involving the calf, shin, ankle, and dorsum of the foot. There is notable lower leg hair loss, scaling of the dorsum of the foot and shin, and a discrete hyperkeratotic papule above the circumferential indentation (see Figure 1).
TELEDERMATOLOGY IMAGING READER REPORT
Interpretation of Images
Problem A: findings
The morphology and clinical presentation of the skin in correlation with past medical history suggests for the diagnosis of stasis dermatitis secondary to venous insufficiency.
Problem B: findings
The hyperkeratotic papule is suggestive of an actinic keratosis.
Skin Care and Medication Treatment Recommendations
Skin care recommendations
Apply a ceramide-based ointment or zinc oxide paste nightly for emollient care. The scaling pruritic dermatitis areas may be temporarily treated with midpotency triamcinolone acetonide 0.1% ointment applied once or twice daily for 1–2 weeks during acute flares, adjusted accordingly by treatment response. It is important to avoid prolonged usage of mid-to-high topical corticosteroids to prevent steroid-induced cutaneous atrophy, predisposition to iatrogenic ulceration, and infection.
Calf-pumping exercises (daily walking, simple seated ankle flexion), compression therapy, and leg elevation while patient is on a recliner or from a supine position for 30 minutes four times daily should be instituted for long-term benefits. The patient should be advised to avoid prolonged duration of standing or sitting with the legs dependent. It is recommended to obtain ankle–brachial index (ABI) before initiating compression therapy to rule out peripheral artery disease associated with smoking and diabetes risk factors.
Actinic keratosis can be treated with cryotherapy.
Type of Visit
Follow up with primary care to determine adequate arterial blood flow in the lower extremities before compression therapy. If ABI is >0.8, proceed with calf compression (30–40 mmHg). Refer to dermatology if stasis dermatitis exacerbates or infection or ulcers develop. Refer to vascular surgery if ABI is severely diminished (<0.5) or if symptomatic claudication occurs at rest.
Stasis dermatitis, or varicose eczema, is a common cutaneous complication of the lower extremities that develops in individuals with underlying venous hypertension and insufficiency from incompetent superior or deep venous valve function. Although not all individuals with venous insufficiency will necessarily develop stasis dermatitis, it is essential to monitor, prevent, and treat stasis dermatitis early on to prevent further exacerbation.
The estimated prevalence of stasis dermatitis is approximately 6%–7% in patients 50 years of age in the United States, which translates to 15–20 million Americans (Patel, Ragi, Lambert, & Schwartz, 2010). Common cutaneous manifestations involve poorly demarcated erythematous plaques particularly apparent near the medial malleolus. The diagnosis is typically made clinically based on physical examination and patient history. Noninvasive imaging modalities such as duplex ultrasound can be utilized to show venous reflux and insufficiency, particularly when the diagnosis of stasis dermatitis is uncertain (Kamper, Altenburg, Das, & Haage, 2017).
Treatment of stasis dermatitis focuses on ameliorating symptoms brought about by the underlying venous insufficiency through lower leg elevation, external compression, attentive wound care, and avoidance of prolonged sitting or standing (Eberhardt & Raffetto, 2014). Venous insufficiency and congestion from fluid buildup results in microtearing of the skin. As a result, fluid and protein leak through the microtears will induce a localized inflammatory response that presents with erythema, scaling, and pruritus (Burrows et al., 2007). Scratching will produce further trauma leading to lipodermatosclerosis, which involves permanent thickening, hardening, dark pigmentation, and skin breakdown that may manifest with sores and ulcers (Paul, Pieper, & Templin, 2011). Stasis dermatitis associated nonhealing ulcers is particularly prevalent around the medial malleolus where there is maximal venous pressure (Renner, Gebhardt, Simon, & Seikowski, 2009). Compression therapy with specialized socks and stockings is a well-recognized form of therapy that requires patient education and compliance (Raju, Hollis, & Neglen, 2007).
Although compression, elevation, and wound care is recommended for most patients, minimally invasive surgical and endovenous therapy such as valvuloplasty, sclerotherapy, and venous bypass or laser ablation by vascular surgeons may be warranted when stasis dermatitis pain and ulcerations become unresponsive to medical management (Eberhardt & Raffetto, 2014). In regards to more novel therapies, autologous platelet-rich plasma in combination therapy with light-emitting diodes may be considered for treating particular cases of refractory stasis ulcers (Park, Kim, Yeo, Kim, & Kim, 2013). Systemic therapies may be considered for the management of chronic venous insufficiency (CVI). Venoactive drugs including flavonoids and rutosides such as Venoruton or Relvène, which are widely utilized in European countries, have shown modest benefits for treating CVI (Aziz, Tang, Chong, & Tho, 2015; Cesarone et al., 2010). More invasive interventions such as endovenous laser ablation, sclerotherapy, and open surgical vein stripping may be indicated for treating refractory CVI (Chodkiewicz, Greenway, & Housman, 2018).
Unfortunately, stasis dermatitis is often mistaken for cellulitis, which translates to an estimated 130,000 unnecessary hospitalizations, over 9,000 nosocomial infections, 1,000–5,000 Clostridium difficile infections, and half a billion healthcare dollars in the United States annually (Weng et al., 2017). The patient and economic burden resulting from misdiagnosis of stasis dermatitis can at least in part be attributed to the lack of dermatology services in many hospitals, emergency rooms, and urgent care settings. One particular retrospective study of 3,662 patients seen in the emergency room determined that cellulitis was the most frequent skin condition that led to hospital admission, highlighting the necessity for on-call dermatologists to provide a higher quality of care (Martinez-Martinez et al., 2011). Although the healthcare infrastructure may not economically garner the support for on-call dermatology coverage in every emergency department and urgent call centers, a unified teledermatology service may offer the next best solution to achieve both patient well-being and decreased societal cost.
Stasis dermatitis is a common chronic condition associated with underlying vascular insufficiency. Nurses are instrumental in providing education to the patient and in reinforcing treatment plans. The mainstay of treatment for stasis dermatitis emphasizes supportive measures, which include elevation of the lower extremities, as tolerated from a recliner position, about 15–30 minutes every 2–4 hours while awake, and then elevation of the legs with pillows while sleeping in supine position; compliance with wearing compression stockings to lessen edema and support the veins; and increased physical activities/exercise to help improve circulation such as calf-pumping exercises throughout the day to strengthen calf muscles. In addition, skin care regimen should include the application of cool compresses or soaks with colloidal oatmeal, followed by liberal moisturization with ceramide-based emollients, especially at night when compression socks are removed. Gentle acidification of the skin with dilute apple cider vinegar may be recommended for 10 minutes, two to three times weekly, to reduce associated inflammation and itching and thereby heal and diversify the skin’s natural flora by reducing unwanted Staphylococcus colonization (Lee & Jacob, 2017).
Aziz Z., Tang W. L., Chong N. J., Tho L. Y. (2015). A systematic review of the efficacy and tolerability of hydroxyethylrutosides for improvement of the signs and symptoms of chronic venous insufficiency
. Journal of Clinical Pharmacy and Therapeutics
, 40(2), 177–185.
Burrows C., Miller R., Townsend D., Bellefontaine R., Mackean G., Orsted H. L., Keast D. H. (2007). Best practice recommendations for the prevention and treatment of venous leg ulcers: Update 2006. Advances in Skin & Wound Care
, 20(11), 611–621.
Cesarone M. R., Belcaro G., Ippolito E., Pellegrini L., Ledda A., Luzzi R., Corsi M. (2010). Clinical improvement in chronic venous insufficiency
signs and symptoms with Venoruton® (HR): An 8-month, open-registry, cost-efficacy study. Panminerva Medica
, 52(2, Suppl. 1), 43–48.
Chodkiewicz H. M., Greenway H. T. Jr., Housman L. (2018). Successful treatment of a scleroderma-associated leg ulcer with endovenous laser ablation. Dermatologic Surgery
, 44(8), 1153–1155.
Eberhardt R. T., Raffetto J. D. (2014). Chronic venous insufficiency
, 130(4), 333–346.
Kamper L., Altenburg A., Das M., Haage P. (2017). Diagnostics and endovascular treatment of venous diseases. Radiologe
, 57(9), 765–778.
Lee K. W., Jacob S. E. (2018). Apple Cider Vinegar Baths. Journal of the Dermatology Nurses’ Association
, 10(1), 59. doi: 10.1097/JDN.0000000000000377.
Martinez-Martinez M. L., Escario-Travesedo E., Rodriguez-Vazquez M., Azana-Defez J. M., Martin de Hijas-Santos M. C., Juan-Perez-Garcia L. (2011). Dermatology consultations in an emergency department prior to establishment of emergency dermatology cover. Actas Dermo-Sifiliográficas
, 102(1), 39–47.
Park K. Y., Kim I. S., Yeo I. K., Kim B. J., Kim M. N. (2013). Treatment of refractory venous stasis ulcers with autologous platelet-rich plasma and light-emitting diodes: A pilot study. Journal of Dermatological Treatment
, 24(5), 332–335.
Patel G. A., Ragi G., Lambert W. C., Schwartz R. A. (2010). Chapter 95—Skin disease and old age. In Fillit H. M., Rockwood K., Woodhouse K. (Eds.), Brocklehurst’s textbook of geriatric medicine and gerontology
(7th ed., pp. 801–809). Philadelphia, PA: W.B. Saunders.
Paul J. C., Pieper B., Templin T. N. (2011). Itch: Association with chronic venous disease, pain and quality of life. Journal of Wound, Ostomy, and Continence Nursin
g, 38(1), 46–54.
Raju S., Hollis K., Neglen P. (2007). Use of compression stockings in chronic venous disease: Patient compliance and efficacy. Annals of Vascular Surgery
, 21(6), 790–795.
Renner R., Gebhardt C., Simon J. C., Seikowski K. (2009). Changes in quality of life for patients with chronic venous insufficiency
, present or healed leg ulcers. Journal der Deutschen Dermatologischen Gesellschaft
, 7(11), 953–961.
Weng Q. Y., Raff A. B., Cohen J. M., Gunasekera N., Okhovat J. P., Vedak P., Mostaghimi A. (2017). Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatology
, 153(2), 141–146.
1The standardized teledermatology reader report format is available for authors on the journal’s Web site (www.jdnaonline.com) and on the submissions Web site online at http://journals.lww.com/jdnaonline/Documents/Teledermatology%20Column%20Template.pdf.