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

Flu surge drives up pressure on general practice

Flu surge drives up pressure on general practice

GP consultations for flu have spiked over the past two weeks, taking levels of the...

General election 2019: five GPs elected as three lose seats

General election 2019: five GPs elected as three lose seats

Five GPs have been elected to parliament, while three high-profile GPs lost their...

What does the 2019 general election result mean for GPs?

What does the 2019 general election result mean for GPs?

General practice is struggling with a workforce in decline, rising demand and a share...

Practices report falling private fees income for second year running

Practices report falling private fees income for second year running

A third of GP practices have seen their income from private and professional fees...

New average fees released for GP private and professional work

New average fees released for GP private and professional work

GP practices can update their prices for non-NHS services following the publication...

Why manifesto promises of more GPs may not make general practice safer

Why manifesto promises of more GPs may not make general practice safer

Politicians of all stripes have promised more GPs during the general election campaign,...