Stasis Dermatitis Management Made Easi(er)

Stasis dermatitis poses complexities in the diagnosis of, patient education for, and management of the disease. These tips will help you improve care for your patients.

Diagnosis

Challenge
Stasis dermatitis starts with edema in the lower extremities, often from post-thrombotic syndrome, and can be complicated by cellulitis or pseudocellulitis (eg, allergic contact dermatitis or lipodermatosclerosis).¹ The cost of misdiagnosis of cellulitis and management with unnecessary antibiotics is estimated to be hundreds of millions of dollars in the United States each year.²

Tip
In 2 recent studies, consulting a dermatologist for inpatients resulted in a reduction in length of antibiotic use without adverse outcomes.^3,4 Another group of investigators using logistic regression analysis found that the combination of unilateral lower extremity involvement (3 points), a white blood cell count higher than 9999/μL (1 point), a heart rate higher than 89 beats/min (1 point), and age older than or equal to 70 years (2 points)—with aggregate points greater than 5 within 48 hours of admission— yielded a positive predictive value for cellulitis of 84.9%.⁵

Patient Perspective

Challenge
Patients often do not know the name of their stasis dermatitis diagnosis, and they have never heard about it in the media. They feel stigmatized by the inability to leave their homes because of drainage from the lesions on their legs and often the associated odor. They have often been told to wear compression stockings but are skeptical that they are a medical treatment and find them uncomfortable and difficult to put on and take off. There is association between adherence to use of stocking and flares of stasis dermatitis.⁶

Tip
Use patient and family education materials via a written explanation of the cause and treatment of stasis dermatitis, as well as information about local medical supply houses that can fit compression stockings and supply assistive devices to put on the stockings. If you are affiliated with an institution that uses EMMI® patient education modules, assign the patient and/or caregiver the “Compression Stockings” learning module, which explains how family members can assist and offers important reminders (eg, never “cuff” the stocking).

Physician Perspective

Challenge
Physicians often fear missing a diagnosis of cellulitis, and patients are happier with a medication than with advice to wear tight stockings every day indefinitely. Stockings are durable medical equipment, and insurance coverage differs from prescription medications. It is often necessary to use home health aides to put on stockings or to involve family members who are not present at an ambulatory visit. All of these factors may lead to overuse of antibiotics and underuse of compression stockings.

Tip
In a recent study, my research team and I developed an inpatient order set to include use of bandages such as Tubigrip, to reduce lower extremity edema for 3 days.⁷ This procedure was followed by a consultation with a physical therapist, who measured and provided the patient a compression stocking and assessed the patient’s need for help putting on the stocking. The order set also included the patient education materials mentioned above. Provided on our in-room televisions was a testimonial video from a patient who was initially miserably itchy because of auto-eczematization from stasis dermatitis; the patient explained that using compression stockings had greatly improved the itching. Use of this order set reduced readmission rates.⁷

Patch Testing

Challenge

Patch testing is not always needed, as continued use of compression stockings will resolve lower extremity dermatitis and generalized auto-eczematization in many patients. Patch testing is useful for patients with prolonged dermatitis despite control of lower extremity edema. The most common allergens among patients with leg ulcers and stasis dermatitis are fragrance (ie, balsam of Peru, fragrance mix 1 and 2, and plants in the Compositae family), lanolin/amerchol 101/ cetearyl alcohol, colophony from dressing materials, topical antibiotics and antimicrobials (ie, neomycin, bacitracin, and benzalkonium chloride), stocking materials (ie, carbamates), and parabens.^8,9

Tip
Small screening studies generally consist of more-potent allergens that sensitize the general population. Patch testing needs to be personalized to the exposure history of this patient population.

Discussion

Physician uncertainty will persist until we have a better biomarker for true cellulitis.¹ Further study is needed to understand the role of chronic irritant dermatitis (due to genetic deficiency in atopic dermatitis and to mechanical stretch in stasis dermatitis) that predisposes to contact sensitization¹⁰ and likely to biofilm formation, leading to sensitization to bacteria and yeast, which in turn leads to more inflammation.

Mechanistically, stasis dermatitis is akin to atopic dermatitis in terms of sensitization to lower-potency allergens, such as lanolin and parabens, as well as possibly to commensal organisms.¹¹ However, in a recent study, my research team and I found that dupilumab reduced the pruritus of stasis dermatitis with auto-eczematization but precipitated a mild psoriasiform dermatitis in a single patient treated with an investigational drug protocol.¹²

Note again the similarity with atopic dermatitis; contact sensitization to less-potent allergens in the local lymph node assay (eg, plants in the Compositae family, lanolin, propylene glycol) is more common in both conditions.¹³ Development of patch test series for these patients with predisposing chronic irritant dermatitis is important for improving the value of patch testing.

Conclusion

Understanding patient perspectives helps us amass the tools we need to improve care for patients with stasis dermatitis. In the inpatient space, these tools were incorporated into an order set that reduced readmission rates. These tools can also be used in the dermatology office for improved patient and family education, as well as resources for compression therapy. Personalized selection of patch test antigens is important for this cohort as well.

1. Goldenberg M, Wang H, Walker T, Kaffenberger BH. Clinical and immunologic differences in cellulitis vs. pseudocellulitis. Expert Rev Clin Immunol. 2021;17(9):1003-1013. doi:10.1080/1744666X.2021.1953982

2. Weng QY, Raff AB, Cohen JM, et al. Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatol. 2017;153(2):141-146. doi:10.1001/ jamadermatol.2016.3816

3. Ko LN, Garza-Mayers AC, St John J, et al. Effect of dermatology consultation on outcomes for patients with presumed cellulitis: a randomized clinical trial. JAMA Dermatol. 2018;154(5):529-536. doi:10.1001/jamadermatol.2017.6196

4. Li DG, Xia FD, Khosravi H, et al. Outcomes of early dermatology consultation for inpatients diagnosed with cellulitis. JAMA Dermatol. 2018;154(5):537-543. doi:10.1001/ jamadermatol.2017.6197

5. Singer S, Li DG, Gunasekera N, et al. The ALT-70 cellulitis model maintains predictive value at 24 and 48 hours after presentation. J Am Acad Dermatol. 2019;81(6):1252-1256. doi:10.1016/j.jaad.2019.03.050

6. Shaikh S, Patel PM, Armbrecht ES, Hurley MY. Patient survey reports association between compression stocking use adherence and stasis dermatitis flare frequency. J Am Acad Dermatol. 2021;84(5):1485-1487. doi:10.1016/j.jaad.2020.06.1030

7. Nedorost S, White S, Rowland DY, et al. Development and implementation of an order set to improve value of care for patients with severe stasis dermatitis. J Am Acad Dermatol. 2019;80(3):815-817. doi:10.1016/j.jaad.2018.10.034

8. Erfurt-Berge C, Geier J, Mahler V. The current spectrum of contact sensitization in patients with chronic leg ulcers or stasis dermatitis - new data from the Information Network of Departments of Dermatology (IVDK). Contact Dermatitis. 2017;77(3):151- 158. doi:10.1111/cod.12763

9. Hou A. Stasis dermatitis in patients referred for patch testing, North American Contact Dermatitis Group Data, 2001-2016. Paper presented at: American Contact Dermatitis Society 32nd Annual Meeting; March 17-18, 2021; Virtual.

10. Lima AL, Timmermann V, Illing T, Elsner P. Contact dermatitis in the elderly: predisposing factors, diagnosis, and management. Drugs Aging. 2019;36(5):411-417. doi:10.1007/s40266-019-00641-4

11. Nedorost S, Hammond M. Art of prevention: Allergic sensitization through damaged skin: Atopic, occupational, and stasis dermatitis. Int J Womens Dermatol. 2020;6(5):381- 383. doi:10.1016/j.ijwd.2020.08.004

12. Schrom KP, Kobs A, Nedorost S. Clinical psoriasiform dermatitis following dupilumab use for autoeczematization secondary to chronic stasis dermatitis. Cureus. 2020;12(4):e7831. doi:10.7759/cureus.7831

13. Kohli N, Nedorost S. Inflamed skin predisposes to sensitization to less potent allergens. J Am Acad Dermatol. 2016;75(2):312-317.e1. doi:10.1016/j.jaad.2016.03.010