Differential diagnoses - Lower leg eczema

Dr Nigel Stollery compares four presentations and offers clues for their diagnosis.

Varicose eczema

Presentation

  • Common in the elderly
  • Occurs on lower legs secondary to varicose veins
  • Usually starts around the medial malleoli
  • Related to leakage of blood and activation of inflammatory cells and fibroblasts
  • Lipodermatosclerosis and more pigmentation often seen

Management

  • Diagnosis usually clinical
  • General advice - elevate legs, avoid trauma and keep active
  • Regular use of emollients and topical steroids for flares
  • Below-knee compression hose, with Doppler assessment of arterial competence first

Atopic eczema

Presentation

  • Most common form of eczema
  • Mainly affects children, but may persist into adulthood
  • Usually affects popliteal and antecubital fossae, but can occur anywhere
  • Often associated with other atopic conditions, such as asthma, rhinitis and hayfever
  • May be a genetic component

Management

  • Mostly managed in primary care
  • Mainstay is emollients, which need to be applied regularly
  • Topical steroids often required in varying strengths, depending on severity and location
  • Secondary infection may occur, requiring antibiotics
  • Alternatives to steroids include topical immunosuppressants

Emollient contact dermatitis

Presentation

  • Rare type of contact dermatitis
  • Can occur due to allergy to lanolin, as in this case
  • Occurs after use of emollients, but may also be seen with topical steroids
  • Redness and irritation usually worse after applying cream
  • Consider if underlying skin condition fails to respond or worsens with treatment

Management

  • Diagnosis may be difficult
  • If suspected, an alternative emollient can be tried initially
  • Patch testing may be required to determine exact cause

Asteatotic eczema

Presentation

  • Distinctive type of eczema with 'crazy paving' appearance
  • Usually on lower legs in elderly
  • More common in winter
  • May be extremely itchy
  • Underlying problem is dry skin
  • Causes include dry or hot environment, overuse of soaps, malnutrition, diuretics

Management

  • Mainstay is regular application of thick emollients
  • Advise bathing less and avoiding irritants
  • Avoid direct exposure to heat
  • Increasing humidity may help
  • In severe cases, topical steroids may be required
  • Dr Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary.

Have you registered with us yet?

Register now to enjoy more articles and free email bulletins

Register

Already registered?

Sign in

Follow Us:

Just published

GPs face wave of abuse and complaints after NHS England face-to-face appointments claims

GPs face wave of abuse and complaints after NHS England face-to-face appointments claims

GP practices have faced a wave of abuse and complaints after a letter from NHS England...

Government denies plan to make GPs 'gatekeepers' of COVID-19 testing

Government denies plan to make GPs 'gatekeepers' of COVID-19 testing

The government has denied plans to make GPs 'gatekeepers' of the struggling COVID-19...

Expansion of NHS 111 service could see direct GP booking extended

Expansion of NHS 111 service could see direct GP booking extended

Plans to expand NHS 111 under measures to prepare the health service for winter could...

Red flag symptoms: Amenorrhoea

Red flag symptoms: Amenorrhoea

Possible causes and red flag symptoms to look out for when menstrual periods either...

GPs demand priority COVID-19 testing to secure workforce in second wave

GPs demand priority COVID-19 testing to secure workforce in second wave

GPs should be among NHS staff prioritised for COVID-19 tests, the RCGP has warned...

BMA to poll members on industrial action over real-terms pay cuts

BMA to poll members on industrial action over real-terms pay cuts

BMA leaders have instructed the union to survey members on possible industrial action...