Venous eczema and brown spots on the legs

Venous eczema and brown spots on the legs: An early warning sign of varicose veins

Brown spots, itching and dry, scaly skin on the lower leg are classic signs of venous eczema (stasis dermatitis) - a skin reaction to long-standing venous hypertension. The condition affects up to 20% of patients with chronic venous insufficiency [1] and is an important warning sign: without treatment, about 1 in 3 patients will develop a venous ulcer within 5 years [2].

---

How does venous eczema develop?

When the venous valves fail, blood flows backwards (reflux) and creates elevated pressure in the veins of the lower leg. This causes:

1. Leakage of red blood cells through the capillary wall
2. Haemosiderin deposits - the iron in haemoglobin permanently colours the skin brownish
3. Chronic inflammation in the subcutaneous tissue
4. Oxygen deficiency in the skin → dry, itchy, scaly surface
5. Fibrosis (lipodermatosclerosis) → firm, constricted skin around the ankle ("inverted champagne bottle")

---

Symptoms you should know

Sign	What it means
Brown spots on the inside of the ankle	Haemosiderin - chronic venous hypertension
Itching and dry skin on the lower leg	Active venous eczema (C4a)
Scaly or weeping skin	Inflammatory phase
Hard, constricted skin at the ankle	Lipodermatosclerosis (C4b) - ulcer risk
White scarred areas	Atrophie blanche - very high ulcer risk
Swelling at the end of the day	Associated swollen legs

---

How to distinguish venous eczema from other skin disease

Diagnosis	Location	Characteristics
Venous eczema	Inside of ankle/calf	Brown pigmentation, concurrent varices/oedema
Contact eczema	Wherever the allergen touches	Acute, itchy, possibly blisters
Atopic eczema	Elbow folds, knees, neck	Personal/family atopy
Cellulitis	Acute, unilateral	Fever, warmth, intense redness
Arterial ischaemia	Toes, dorsum of foot	Pain, cool skin, weak pulses

Confusion with cellulitis is common - venous eczema is not treated with antibiotics [3].

---

When to see a doctor?

Contact your GP or a specialist surgeon if you have:

• Brown spots or discolouration on the lower leg
• Itchy, scaly skin for several weeks
• Visible varicose veins + skin changes
• Hard, firm skin around the ankle
• Previous venous ulcer
• Associated heavy, tired legs or spider veins

---

Work-up

1. Clinical assessment and CEAP classification (C4a/C4b).
2. Doppler ultrasound (duplex scan) - maps valve failure and reflux [4].
3. Ankle-brachial index (ABI) before compression therapy.
4. Patch test if secondary contact allergy to creams or dressings is suspected.

---

Treatment

1. Treating the underlying cause - the only thing that stops progression:

• Endovenous laser ablation (EVLA/EVLT) of incompetent trunk veins is first-line.
• The treatment significantly reduces eczema, swelling and recurrent ulcers [5].

2. Compression - the cornerstone of symptom control:

• Class II compression stockings (23-32 mmHg) daily
• Requires normal ABI

3. Topical treatment of acute eczema:

• Moisturiser several times daily (unscented)
• Short-term medium-strength steroid cream (1-2 weeks) for active inflammation [6]
• Stop using wet wipes and soap on the legs - use a gentle emollient
• Avoid lanolin and perfumed products (common contact allergens)

4. Lifestyle:

• Daily exercise → activates the calf muscle pump
• Elevate the legs 15-20 min several times daily
• Weight loss if BMI >25
• Avoid long periods of standing or sitting

---

Treatment at Kirurgen.dk

We offer Doppler ultrasound and endovenous laser ablation (EVLA/EVLT) under the public health insurance scheme. Early treatment prevents progression to a venous ulcer. See also our articles on treatment of varicose veins, spider veins and swollen legs and ankles.

---

References

1. Sundaresan S, Migden MR, Silapunt S. Stasis dermatitis: pathophysiology, evaluation, and management. Am J Clin Dermatol 2017;18(3):383-90.
2. Robertson L, Lee AJ, Evans CJ, et al. Incidence of chronic venous disease in the Edinburgh Vein Study. J Vasc Surg Venous Lymphat Disord 2013;1(1):59-67.
3. Weaver J, Billings SD. Initial presentation of stasis dermatitis mimicking solitary lesions. J Am Acad Dermatol 2009;61(6):1028-32.
4. Gloviczki P, et al. The 2022 SVS/AVF/AVLS clinical practice guidelines for the management of varicose veins. J Vasc Surg Venous Lymphat Disord 2023;11(2):231-61.
5. Gohel MS, Heatley F, Liu X, et al. Early endovenous ablation in venous ulceration (EVRA trial). N Engl J Med 2018;378(22):2105-14.
6. Nedorost ST. Generalized dermatitis: a practical clinical approach. Dermatol Ther 2012;25(2):143-8.