380: What’s Stasis Dermatitis (And What Does This Leg Rash Mean)? w/ Dr. Peter Lio

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Ever heard of stasis dermatitis? If so, I’m willing to bet that you were diagnosed with this!

Whether you notice your lower legs swelling, turning red, or becoming unbearably itchy, it’s not just dry skin or aging. These leg dermatitis rash symptoms could be a sign of a deeper circulation issue.

That’s right… the leg and foot dermatitis rash known as stasis dermatitis is an important clue. Left unchecked, it can lead to painful ulcers, skin infections, and even more serious complications.

Many people (and even doctors!) mistake stasis dermatitis for cellulitis, leading to unnecessary rounds of antibiotics and even hospitalizations. In one shocking case, a patient was admitted to the hospital 11 times before getting the correct diagnosis! And did you know that this condition doesn’t just affect your legs? It can also appear under the belly, on the lower back, or anywhere blood is pooling due to venous insufficiency.

To unpack this under-discussed but critical skin issue, I’m joined by Dr. Peter Lio, a board-certified dermatologist and leading expert in eczema and inflammatory skin conditions.

If you’re not familiar with Dr. Lio, he’s a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine. He received his medical degree from Harvard Medical School, completed his internship in Pediatrics at Boston Children’s Hospital, and his Dermatology training at Harvard where he served as Chief Resident in Dermatology. While at Harvard, Dr. Lio received formal training in acupuncture. Dr. Lio has written a textbook on Integrative Dermatology and has published over 100 papers.

Dr. Lio will break down how status dermatitis develops, why it’s often misdiagnosed, and what you need to know to recognize it.

If you or someone you know has unexplained swelling, itchy skin, or redness on their lower legs and feet, this episode is a must-listen. Let’s dive in!

Or, listen on your favorite app: iTunes (Apple Podcasts) | Spotify | Stitcher | TuneIn | Subscribe on Android

 

In This Episode:

• What is stasis dermatitis, and why is it often misdiagnosed?
• The connection between venous insufficiency and itchy dermatitis leg rash
• Why stasis dermatitis primarily affects the lower legs
• Who is most at risk for stasis dermatitis?
• The shocking story of a patient who was hospitalized 11 times before getting the right diagnosis!
• What varicose veins warn you about
• Cellulitis versus stasis dermatitis
• Compression stockings—do they really help?
• Simple at-home strategies to improve circulation and reduce stasis dermatitis

 

Quotes

“Cellulitis literally just means the soft tissue, or skin, has an infection. It's typically caused by staph or strep, those two common bad-guy bacteria.”

“Taking walks is really important because that's a lot of the way that our blood vessels work, the veins require muscular movement.”

 

Links

Find Dr. Lio online | Twitter | Facebook

Healthy Skin Show ep. 257: Itchiness + Histamine Intolerance – Why Am I Itchy?

Healthy Skin Show ep. 246: Everything You Need To Know About Skin Tests (Done By Your Dermatologist)

Stasis Dermatitis: An Overview of Its Clinical Presentation, Pathogenesis, and Management

Overview of Venous Hypertension

Chronic Venous Insufficiency (CVI)

Unna's Boot – an overview

 

380: What’s Stasis Dermatitis (And What Does This Leg Rash Mean)? w/ Dr. Peter Lio

Jennifer Fugo (00:07.97)

Dr. Lio, it is such an honor yet again to have you back on the Healthy Skin Show. Thank you for being here to talk about stasis dermatitis.

Peter Lio (00:14.552)

Thank you for having me. It's always a pleasure.

Jennifer Fugo (00:16.728)

Well, you are one of the fans’ favorites because you're so good and so compassionate at sharing with people what these conditions are. And one of these conditions, actually, I have gotten so many requests in our customer support box about, which I was not really familiar with, is something called stasis dermatitis. So can you explain to us what exactly that is and is it simply a dermatitis leg rash?

Peter Lio (00:41.226)

Absolutely. So venous stasis dermatitis, or sometimes called venous stasis eczema, it really is a form of inflammation in the skin that is very much an eczema. There's redness, there's dryness and scaliness, sometimes if it's very acute it can be open and oozy, so it is one of the eczemas. But it generally is affecting the lower legs where there is venous insufficiency, where the blood return is not able to do its job, and there are a number of reasons for that, which we can talk about in a minute, but when the blood is sort of pooling in that area. Now it turns out it doesn't have to just be the legs. For people, for example, if they're bedridden, it might be the lower back and the buttock area. Sometimes, if people have kind of a larger belly and it's hanging over, sometimes we can actually see stasis eczema or stasis dermatitis at the bottom of their belly because the same process is happening. The blood is pooling in that extra tissue.

Jennifer Fugo (01:28.497)

Wow. And when you say venous, just for everybody who's listening, you mean the veins, correct?

Peter Lio (01:33.972)

Exactly. So our circulatory system, the arteries bring the fresh oxygenated blood to the tissue, the veins bring it back to the heart so it can get re-oxygenated. And the veins are a little looser, they're a little softer, they're not under pressure where your heart pumps that blood arterially. So that gets it to the place. But sometimes it has to kind of rely on different aspects of muscle, and the veins actually have little valves in there that prevent it from backflowing, but if the veins are damaged or if you have a heart issue, or if you already have had the vein stretched out for some reason and it's swelling in the area, then the blood can pool. And when that happens, different factors kind of leak out of the blood, inflammatory cells and different things. I don't think we even fully understand it, but it causes secondary inflammation in the skin. And basically, I always say to the patients when there’s swelling, your skin really doesn't like this, so we have to get rid of the swelling so your skin can heal.

Jennifer Fugo (02:24.364)

Now, are you typically the first person or physician who would diagnose this, or is this dermatitis on legs sometimes caught by other doctors? Because obviously it has to do with your veins and your cardiovascular system. So how would this dermatitis leg rash get diagnosed, and is this something that you tend to see, and is it a warning sign?

Peter Lio (02:44.822)

It definitely can be a warning sign. I would say we see it a fair amount, probably the cardiologists see it the most. Many patients with a known heart issue, if they either have a problem where they're not pumping their blood at maximum efficiency, they are going to have some amount of venous insufficiency where the blood is pooling back in the legs. And I imagine if you go to any cardiology office, you'll see a lot of the patients, their legs are swollen and many of them may have stasis dermatitis. We see a lot of them once it becomes symptomatic because, and I've actually written a paper about this many years ago, it looks really confusing. If you don't know what this is, then it's confusing. You see redness and swelling and it's tender, so people often assume it's an infection.

And I'll tell you a story I had years ago, I was still in training, I had a patient, very nice lady who had a history of some heart issues and would get terrible swelling of her legs, and then they would turn red and tender and swollen. And she had venous stasis dermatitis. But every time she'd go to her primary doctor, they'd say, uh-oh, it looks like you have an infection, you've got cellulitis. So they put her on oral antibiotics, and of course it wouldn't get better because it's not an infection, and they’d say, you’ve got to go into the hospital. So this patient finally got sent to dermatology, I'm not exaggerating, she had 11 hospital admissions, 11 times. And each time she'd go to the hospital, they’d put her on IV intravenous antibiotics for days and all that stuff, and she said they took great care of me, but then I'd get a bit better and go home. And then she said, well, why would it help if it wasn't an infection? I said, well, tell me something else you do when you're in the hospital. She said, well, nothing, I just laid in bed all day. And I said, exactly. You put your feet up. And she said, my goodness, you're right, because when I'm in my wheelchair, they're just dangling all day long, I'm seated this way. And that was the moment. So once we were able to help her, then she never got hospitalized again in the several years that I took care of her after.

Jennifer Fugo (04:32.763)

Wow, so who is most at risk for stasis dermatitis or this dermatitis on legs? Is this like something that you would see in children or is it?

Peter Lio (04:40.116)

Almost never in kids. Generally, these are going to be older patients, although you can see it in sometimes young adults. But the truth is usually it's people that have a history of some issue with their heart or with fluid retention, or if they actually have a vein problem. So people with big varicose veins, that can be a family issue where the veins are, again, not working properly or the venous valves are actually not doing their job of keeping the blood from backflowing. Those are the people we usually see it in.

Jennifer Fugo (05:07.918)

Okay, so I have to ask, because I literally have thought until this point that varicose veins were like a harmless thing. Maybe they get unsightly the more pronounced they are, but am I mistaken in thinking that varicose veins could be a red flag for issues?

Peter Lio (05:24.098)

I think generally speaking, in the world, varicose veins are very common and they're usually fine. The people that have them are healthy and they're fine. But if they get bad enough, not only can they be symptomatic and sore, but they really can be the sign that there is something problematic, that the veins are not doing their job, I mean, literally the blood is pooling. That's what you're seeing, that varicosity is a swelling of the vein. So it is abnormal to some degree. And again, most of the time it’s probably fine, but if you do have it, especially if it's on one leg or if it's a sudden thing, that really can be the sign of another reason.

So we talked about heart issues or vein issues, but another thing that can happen is a blood clot. If you have a blood clot in your leg, then, or even a little bit higher, if it's pushing up towards your pelvis or abdomen, that can actually, again, cause the blood not to be able to flow. It's blocked off, and then you get backflow, and then you can get stasis eczema or stasis dermatitis in one leg. And that's another scary thing. So there are reasons that if this happens quickly, it's kind of a big deal. If it's happening slowly, it's probably not dangerous, but it is a problem. And it's something we want to make sure we address.

Jennifer Fugo (06:25.39)

So this is reminding me of a man who was a patient of my dad's many, many years, probably 15, 20 years ago. He had, his lower legs were like purple, they were purple in color and looked so swollen and whatnot. And I had asked him if he had seen the doctor for that because obviously it did not look appropriate and I was just trying to double check, are you getting certain things checked? And I know that he was diabetic, I do remember that he had told me that. And now this is making me think that maybe this (stasis dermatitis) was an issue for that man, because I would imagine when your legs become discolored. So obviously, if it's more whitish, like a paler toned skin, it may look like what, reddish, purplish, but in other skin tones, is it possible that this might look a little different?

Peter Lio (07:23.572)

Absolutely. You know, if there's a lot of melanin in the skin, more richly pigmented skin, you might have trouble seeing the redness. It might actually just look a little darker. Sometimes erythema redness can look just more like darker skin, so it can be confusing. And of course, another piece is that when you get inflammation, we know that we get that pigmentation that comes after, post-inflammatory hyperpigmentation. So that's the other piece. People that have recurrent stasis eczema or dermatitis, they'll often have kind of dark brown patches on their legs. And that can be a sign, even in between flare-ups. They'll say, what do you think is going on, trust me, please believe me, I really do get redness. I'm like, I believe you, I see the leftovers, I see the pigmentation, so I know that you're getting inflammation, so we have to talk about that.

Jennifer Fugo (08:04.11)

So one thing as I was reading about this, again, I was not really familiar with this concept of venous hypertension, so this high pressure in the veins, that this can cause some really serious issues, which obviously impact, I mean, it can lead to amputation. It can be very serious, I read it can cause cellulitis, it can cause ulcers on the leg. Can you talk a little bit about why that would happen? I just want people to take this seriously, because I think this could be something that you might say, oh, well, I'm older, I don't walk around as much, I don't move as much. And we just sort of sometimes assume that some of these things are normal because of aging, but this kind of sounds like something that you should see a doctor about.

Peter Lio (08:54.57)

Absolutely. I mean, you're right. Many people, especially as we get older, if you're standing a lot, let's say you work, you’re a cashier at a counter all day, it is not crazy to have a little bit of swelling on your legs at the end of the day. Or a surgeon who's doing a 12-hour case, we were doing that as medical students, your legs would be a bit swollen. In fact, many people who work in operating rooms or are on their feet all day, they will wear compression stockings, you know those really tight stockings you have to pull on, to keep their pressure up on their lower legs. It's really helpful. Actually, it can make you feel a lot better, make your feet and legs feel better. So a lot of people who stand for their jobs will wear compression stockings. And that of course is one of the treatments that we do for venous stasis dermatitis as well.

Now, if you develop it quickly though, that's when I get worried. It's like all of a sudden you're getting swelling in your legs and it can be very serious. And of course left untreated, as you say, it can lead to really bad swelling, redness, open sores, deep ulcers that can be very difficult to heal. And even though the patient I described, it was not really a cellulitis infection, it was kind of mimicking it, it looked like cellulitis, but it absolutely can become true cellulitis because the blood flow is bad and the skin barrier is damaged. So you really can open the door. And then you can imagine if you get an infection in an area of skin that has swelling and slow blood flow, then you can be in big, big trouble. And so, we don't want to mess around with that. That's why it's so important to prevent it and not be reactive every time.

Jennifer Fugo (10:14.232)

Yeah, and so for those who don't know what cellulitis is, what is that, and does cellulitis itch?

Peter Lio (10:18.984)

Cellulitis literally just means the soft tissue, or skin, has an infection. It's typically caused by staph or strep, those two common bad-guy bacterias. And that's like, maybe a good story would be somebody cut their leg when they were out in the woods, they got a scrape and then it got a little red around it. And then all of sudden there's a big red patch and it's sore, and when they touch it, it hurts them, and now they're getting a fever. They’d say, uh-oh, you have cellulitis, you now have an infection of your skin. It's not something we can just put a little topical antibacterial on, now you need either an oral antibiotic or you're going to need an intravenous antibiotic to help fight this infection. And that's the kind of thing, left untreated, eventually it can go into your blood, it can keep creeping up, it climbs up your lymphatic system, and you can get in serious trouble. So cellulitis is a serious infection.

Jennifer Fugo (11:02.266)

And one thing about this, this would probably make sense, is that, at least I read, that this stasis dermatitis can be quite itchy. And you've talked about how when we mechanically damage the skin, you don't mean to do that, but you're scratching because it's so itchy, obviously that can introduce bacteria. So do you know why this could be an itchy condition?

Peter Lio (11:25.726)

Absolutely. I mean, it really does fit at home in the eczema, right? So we know our eczemas are complicated. They really refer to this concept where there is inflammation and all these inflammatory mediators. And we know some of the characters now, IL-4, IL-13, IL-31, which is the master itch cytokine. So there are receptors on our nerve endings, when you release certain kinds of inflammation, literally we interpret that as itchy, so it's driving itch. But then once the barrier is damaged, we have bacteria overgrowing, we have allergens and irritants, things bothering the skin, and our immune system reacts even more to that. We know that staph, when staph is present on the skin, and again, anytime there's broken skin, you can probably get some staph sitting on the top, it's releasing those toxins, like alpha-toxin and delta-toxin. So, it's making things that can literally, the V8 protease, that actually causes itch directly. So, all these pieces make our skin itchy and uncomfortable, and then, of course, that can start the scratch-itch cycle. People start rubbing it, which is really bad, as you say, mechanically damaging it and fueling this whole fire.

Jennifer Fugo (12:24.814)

So if someone does get this diagnosis of the stasis dermatitis, I just want them to hear this. It sounds like they should go see a cardiologist in addition, like you should investigate this in some regard.

Peter Lio (12:39.616)

Definitely if it's new onset, what I’d say is this, we'd start with our primary care doctor. Most primary care doctors are really good at knowing what to do and will figure out if we need to do an ultrasound to check to see what's going on with the blood vessels. Do we need to check for a blood clot if it's new? Do we need to ask what's going on with your heart? Why is your heart, is it not effectively pumping, is there a problem with that that we need to look at? So then they might refer you to a cardiologist. I think it's tough for most people just to go find a cardiologist straight up, but starting with primary care and just saying, hey, can we talk about this? This seems new or worsening to me. So that step one.

And then step two, if they're still having trouble, most of the time, as I say, I would argue the vast majority of time, they're going to say, yeah, it's just a little bit of venous stasis, it happens. But if they're still getting this irritating itch, then it's time to come see us, it's time to come see dermatology. And I'll say, okay, now we'll talk about some of the things we can do to help prevent the inflammation and minimize this. Truth be told, the only person who can really fix it if there's such a thing would be the person like a cardiologist if it's a heart problem, or a vascular surgeon if it's a vein problem. If the veins are really damaged for some reason, we might need a vein surgeon, a vascular surgeon, to go in there and either do the surgery, or do sclerotherapy, or laser therapy, they can actually put a laser into the blood vessels, into varicose veins, and zap them. So they have all these tools. It's outside of my ken, but I would refer, you need to see a vascular surgeon who will help us here, which is really important.

Jennifer Fugo (13:58.008)

So for someone who's coming to see you who has this, you mentioned the compression socks. Is there anything else that you can do, or you suggest, for somebody who has this?

Peter Lio (14:09.966)

Yes, we have lots of little tricks. So compression stockings are great. The problem is, first of all, for older people, it's very tough to put them on. Even for younger people, and I'm not that young anymore, but even when I was like in my 20s, I remember I tried it in med school. They said, try it, see what you think, see if you can do this. And we were all like on the floor pulling and grunting, and it's really hard, especially if you wear the appropriate. Now, sometimes you can buy a very low level, they measure it in millimeters of mercury, the pressure. If you get a very low one, then it's not much harder than putting on a sock, but to get what you really want, this kind of clinical compression level, then it is difficult to put on and off. So sometimes the older folks need someone to help them if they have trouble bending, or moving, or weaker hand strength. So that's one issue.

The other problem is that they can be uncomfortable. They're hot and they can be itchy sometimes, so people are like, I hate wearing them. So one of the things that we'll do, especially if it's very acute you really can't, if there's sores and stuff, you don't want to put this on somebody, it's difficult. So what we'll do in the short term is we'll actually do something called an Unna boot, and an Unna boot is one of my favorite techniques and we use them for a lot of things, but this is one of the best things they're for. So what it is, and can actually purchase them over the counter, all it is is a gauze roll that is impregnated with zinc oxide, and also typically with sort of an iron oxide and calamine lotion type thing. But usually we get the colorless one, the modified Unna boot that's just zinc oxide, so it's diaper paste on gauze, but it's done in a way that’s kind of hard to do at home. It's not very expensive, they're just a few dollars per roll.

And what we do is we clean the leg really well. We might put on cortisone or a non-cortisone anti-inflammatory medicine, or if we didn't want to do that we could just use a moisturizer, and then we'd wrap that leg with the Unna boot, not too tight, sort of gently wrapping, but we'd start a little tighter at the ankle, a little looser, a little looser, so we kind of make a gradient of pressure. And then it's kind of, it's cold and damp and zinc oxide, it's white diaper pasty, or if we use the old fashioned one that also has the calamine, so it's pink. And then we put like another wrap, like an ace wrap, or if they don't want to do that, they can just put like a sweatpant over it. And then they wear that for up to a few days, you can even do it for several days. Usually I have people sleep with it, and then I have them replace it the next day, come back in, or in a day or two, and they'll do that for a few days in a row, and it is the most dramatic thing you've ever seen in your entire life. An Unna boot wrap, because it gets rid of the extra fluid, it protects and heals the skin, if you use it with a medicine, it pushes the medicine in. So people come in looking terrible and like three days later for the change, they're like, it's a miracle, it's brand new. It's so powerful.

Jennifer Fugo (16:39.886)

Well, it's also interesting because you're helping to move the fluid out of the leg and you're aiding the circulatory system. So I'm sure there's a lot of different things happening at the same time. Would you also say, if someone could be more mobile, to try to walk and not be stationary?

Peter Lio (17:00.244)

Absolutely. Taking walks is really important because that's a lot of the way that our blood vessels work, the veins require muscular movement. So taking walks regularly, they don't have to be super long, you don't have to hike up a mountain. But even if your mobility is limited, doing the best you can. Elevating those legs when you're sitting, if you can get them above your heart, we say get them higher up than your heart or your chest. That really will help you. Also, we know that not standing for long periods in the same position. So if somebody's at a job where they have to stand, sometimes we'll write a note, can they please sit for part of it, or can they move around for part of it? Can they do something to break that monotony, because otherwise it really can be made worse.

Jennifer Fugo (17:38.322)

Wow. Well, thank you very much for clarifying this and I hope that everybody who hears this who's been writing in and asking me questions will, I mean this is really helpful. Like I said this is not something that I had any experience with, and I honestly didn't even know that you could have hypertension in the veins. So this has been, even for me, this has been very enlightening. And it's a part of your body that we don't tend to think about. We think about the heart, we think about our arteries, but we don't think about what's bringing all that, well, our blood that's deoxygenated and all of the waste back on up to do all the things we need to do, and how that could then impact the skin. So thank you so much for sharing all of that.

Peter Lio (18:22.646)

It's my pleasure, thank you for having me.