Treating Stasis Dermatitis
As this is my first attempt at blogging I will start by introducing myself. My name is Raymond Shulstad, DNP, ARNP-C, BC, DCNP. I have been practicing dermatology for the past 11 years in the Tampa Bay area. I completed my DNP in December of 2009 at the University of South Florida, after finishing my dermatology residency. As with all areas of medicine, it is important to guide treatments on the evidenced-based practices that are available. However, some of what we all do is empirical and knowing some tricks to the trade can be helpful at optimizing patient outcomes.
I am a strong advocate for educating our patients and keeping interventions and treatments as simple as possible. It is my belief and has been my experience that this leads to higher compliance and better outcomes. The treatment for a condition shouldn’t be more stressful than the condition itself. I operate under the K.I.S.S. (keep it simple silly) principle.
One condition that I find to be chronically mismanaged or over-managed is stasis dermatitis. This condition is caused by edema in the lower legs and can result in mild erythema and itching in the early stages to blister and ulcer formation if untreated. Most patients I see with this come to the office saying that they have been given “water pills” or T.E.D. hoses to get the excess fluid out of their legs.
Most will not wear the hose due to discomfort and the water pills are of little use if the edema has progressed to the point of causing stasis dermatitis. Patients are also given topical antibiotics and some are being treated by wound care are receiving dressing changes regularly to treat ulcerations.
The next time someone presents with this condition in clinic I encourage you to try a simple approach that educates and empowers the patient to treat the current eruption and prevent further problems. After explaining that the irritation in the legs is being caused by the edema, I explain to them that the only way to treat this properly is to get the fluid out. To do this we use gravity to our advantage. It is, after all, gravity that is causing it.
Patients know that blood is being pumped by the heart to all parts of the body. I explain to them, though, that nothing pumps the blood back. It is pushed back by the blood being pumped out from the heart.
In the lower legs, when valves are failing, it is easier for the fluid to third space, causing edema and eventually stasis dermatitis, than it is for it to fight gravity and return to where it belongs. Fluids will always follow the path of least resistance. In these cases the force of gravity keeps the fluid in the legs. Since there is no way to reverse the valve damage, it is vital to long term control to keep the edema down to a minimum.
Instruct your patient to elevate their legs for 15 minute every two hours. Additionally, have them go to bed with the legs elevated. Elevation must be above the level of the heart or this intervention will be ineffective. By allowing the forces of gravity to work on the edema, it is now easier for the fluid to be reabsorbed and returned to the heart for circulation or elimination through the kidneys than it is for it to stay in the legs. Again, liquids will always follow the path of least resistance.
Low- to mid-potency topical steroids can be used if pruritis is present but in most cases it is not needed. Petroleum-based emollients can be applied to help hydrate the skin and prevent scaling and irritation. This treatment should be continued for two weeks and then re-evaluated. You will be amazed at the results and so will they. Keep it simple: no hose, no dressing changes, just using gravity to our advantage.