The treatment of venous eczema
Most family doctors, dermatologists and nurses make an assessment of what they can see on the skin surface rather than thinking about what might be the underlying cause. Therefore when they see eczema on the lower leg, rather than arranging for a duplex ultrasound scan to find out if there is venous reflux or “hidden varicose veins”, they either recommend steroid cream for the eczema or mistake it for an infection (often incorrectly calling it “phlebitis“) and give antibiotics.
Steroid cream will make the skin look better in the short term, as steroids always decrease inflammation. However as the inflammation is being caused by venous reflux, and nothing has been done to decrease that, once the steroid effect on the skin has worn off then the condition returns and even worsens. If steroid cream is used in the long-term, the skin gets very thin and can become permanently discoloured. Antibiotics on the other hand, have no effect at all and can be detrimental to the bowel and cause resistant bacteria to be formed.
Turning now to treatments that can work, the simplest and cheapest is graduated compression stockings.
Graduated compression stockings, when fitted correctly, reduce the impact of the blood refluxing down the veins, reducing the information in the skin and flesh around the ankles. Therefore if graduated pressure stockings are put on as soon as the patient gets out of bed in the morning, and worn when ever the patient is standing up, they reduce the impact of the venous reflux back down the veins which reduces the inflammation and allows the venous eczema to start to heal.
Unfortunately, as soon as the graduated pressure stockings are removed, the process reverts back to previously and the venous eczema recurs. Therefore medical graduated pressure compression stockings are very good to treat venous eczema in the short term or in those people who do not wish to have surgery or cannot have it for any other reasons.
The only treatment that can cure venous eczema is the successful treatment of the underlying venous reflux.
In order to do this, a high resolution duplex ultrasound scan needs to be performed which checks all of the veins, both superficial and deep, in the affected leg, identifying any veins that have lost their valves and that are allowing blood to reflux backwards down them.
In the past it was thought that only the Great Saphenous Vein (GSV) and Small Saphenous Vein (SSV) were important in venous reflux disease. However it is now known that incompetent perforating veins (IPVs) can cause venous eczema and less commonly, pelvic venous reflux or other abnormal veins.
Once the refluxing veins have been identified, treatment can be planned depending on:
- which vein or veins are involved
- what size they are (diameter)
- how long they are
Treatment options include Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA), TRansLuminal Occlusion of Perforators (TRLOP), phlebectomy, ultrasound guided foam sclerotherapy or coil embolisation of pelvic veins. There are some new techniques being developed that may also be useful including mechanical sclerotherapy, steam vein sclerosis and “glue” to stick the vein together from the inside.
Once the optimal treatment has been performed successfully under local anaesthetic, and all the venous reflux has been abolished, the venous eczema will slowly improve by itself over time. There does not need to be any other treatments such as cream nor graduated pressure stockings although this might be helpful for symptomatic relief in the healing period.
When considering treatment, one should also think about the consequences of not having treatment.
In venous reflux disease, patients usually deteriorate from varicose veins through swollen ankles to skin damage such as venous eczema and then on to leg ulcers. If the venous eczema is not treated adequately, the venous reflux disease will continue to deteriorate, causing more skin damage and then leg ulcers in a proportion of patients.
As such, anyone with venous eczema is recommended to have proper investigation and treatment to cure their venous eczema for once and for all.
What you should do if you have venous eczema
You may find it acceptable to have medical graduated pressure compression stockings fitted for temporary relief or to avoid surgery, but do remember this will mean that you are not going to have a cure.
Ideally you should insist on being sent to a vein expert with a good reputation for venous surgery who has access to local anaesthetic treatments providing Endovenous Laser Ablation (EVLA), Radiofrequency Ablation (RFA), TRansLuminal Occlusion of Perforators (TRLOP), phlebectomy, and ultrasound guided foam sclerotherapy.