Title: GZ / The Grenz Zone Season 1 / Episode 14
Tags: GZ DermnetNZ Waikato

Q: Stasis dermatitis, also known as gravitational dermatitis or stasis eczema, is commonly seen on the [...] of patients with [...]
A: lower legs; venous insufficiency

Q: Pathogenesis of stasis dermatitis?
[...]
A: Venous valves become incompetent → venous hypertension → extravasation of fluid and RBCs out of the vessels and into the interstitium → edema, hemosiderin deposition
Back Extra: Commonly seen in those who have spent a lot of time on their feet

Q: Stasis dermatitis is typically bilateral but may be unilateral if patient has had [...], prior [...], or
[...]
A: trauma; cellulitis; surgery
Back Extra: e.g. vein harvest for CABG

Q: [Acute/Subacute/Chronic] forms of stasis dermatitis often present as bright red, warm, tender patches or plaques that may have vesicles or serous weeping fluid
A: Acute
Back Extra: e.g. vein harvest for CABG
Chronic: more scale and hyperpigmentation due to hemosiderin deposition

Q: Chronic stasis dermatitis presents with more scale and hyperpigmentation due to [...] deposition and possibly lipodermatosclerosis
A: hemosiderin

Q: What is lipodermatosclerosis?
[...]
A: Sclerosing panniculitis of the lower extremity
Back Extra: Seen more commonly in chronic cases of venous insufficiency
Presents as more indurated pink-to-red plaques caused by fibrosis due to fibrinogen leaking out of the veins deposition
Advanced cases may cause the leg to have an ‘upside-down champagne bottle’ appearance

Q: Besides progression to lipodermatosclerosis, what are 3 complications that arise as a result of stasis dermatitis?
[...], [...], and secondary [...]
A: Contact sensitization; autosensitization (id reaction); infection
Back Extra: Id reaction shown below (very non-specific reaction)

Q: Patients with stasis dermatitis have a higher rate of contact sensitization (allergic contact dermatitis), often due to pts using [...] on rash since they think it is infected
A: triple abx ointment
Back Extra: May also have an impaired skin barrier and increased vascularity and inflammatory cells present
Explain to patients that they are essentially rubbing poison ivy on themselves

Q: What is an id reaction?
[...]
A: Immune mediated eczematous or papulovesicular lesions that occur at distant sites from primary rash
Back Extra: Often due to tinea pedis, stasis dermatitis, or scabies

If trying to distinguish cellulitis from stasis dermatitis, remember that cellulitis will exhibit the four cardinal signs of inflammtion, which are red (rubor), hot (calor), swollen (tumor) and painful (dolor)
Back Extra: In addition, unilaterality also supports a diagnosis of cellulitis
Patients may uncommonly also have systemic signs or leukocytosis, as well as vesicles, bullae, or petechiae, so don't let those throw you off

Q: Unilateral red leg is more suggestive of [...], while bilateral red legs are more suggestive of [stasis derm/cellulitis]
A: cellulitis; stasis dermatitis
Back Extra: Stasis dermatitis is typically bilateral but may be unilateral if patient has had trauma, prior cellulitis, or
surgery

Q: Scale on red leg(s) is more suggestive of [stasis derm/cellulitis]
A: stasis dermatitis
Back Extra: Scale takes time to develop!

Q: Exquisite pain or crepitus with red leg(s) should make you consider [...] in your differential, while unilateral pitting edema with a positive Homan's sign should make you consider [...]
A: necrotizing fasciitis; deep vein thrombosis

Q: If erythema within a red leg improves after elevating the leg for 30 seconds, , think [cellulitis/stasis derm]
A: stasis dermatitis

Q: Painful red leg(s) is more suggestive of [...], while itchy red leg(s) are more suggestive of [stasis derm/cellulitis]
A: cellulitis; stasis dermatitis
Back Extra: One of the four cardinal signs of inflammation is pain
Not all stasis dermatitis is pruritic, but its presence is suggestive

Q: While not necessary, a biopsy of stasis dermatitis would show [...] correlating with the dermatitis seen clinically, increased proliferation of capillaries below DEJ (reactive to the [...]), extravasated RBCs with hemosiderin deposits, and possibly dermal fibrosis at later stages
A: spongiosis; relative anoxia
Back Extra: May not be helpful; pt already has poor circulation and likely will not heal well

Q: Treatment for stasis dermatitis?
[...]
[...] + [if secondary impetiginization] for dermatitis
A: Compression & Elevation; Topical corticosteroids; Mupirocin
Back Extra: o Compression stockings (>20 mmHg)
o Severe: Serial Unna Boots or prednisone
o Elevate above level of heart as much as possible
Patient education
o No cure, only control with above measures; may have another case of stasis dermatitis in future
o Empower pt to use compression + elevation

Q: Asteatotic dermatitis, also known as [...], presents as diffuse xerosis with fine scaling that progresses to inflammation and cracking of the skin that resembles [...] or a(n) [...]
A: eczema craquelé; cracked porcelain; dry riverbed
Back Extra: Is considered the severe form of xerosis, typically affects adults >60
Pt experiences pruritis and can be painful when cracking of skin is deep enough to cause fissures
Weeping, crusting, and bleeding occur on occasion

What can exacerbate xerosis bad enough to cause eczema craquele
Low Humidity
Harsh soaps
Prolonged or frequent hot showers
Heating with wood stoves
Hypothyroidism
Renal failure
Liver disease, malnutrition
HIV
Sjögren's syndrome

Q: Treatment for eczema craquelé involves
Avoiding Triggers
Apply [...] within 3 minutes after shower
Topical [...] + [...] for itching
A: moisturizer; corticosteroids; antihistamines
Back Extra: Vanicream, Cetaphil, Cerave, Vaseline w/in 3 minutes after shower while skin is damp to hold moisture