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.

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