Lower leg eczema: differential diagnosis

Differential diagnosis of lower leg eczema including varicose eczema, atopic eczema, emollient contact dermatitis, asteatotic eczema. By Dr Nigel Stollery.

Varicose eczema
Varicose eczema



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


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

Atopic eczema
Atopic eczema



  • Most common form of eczema, mainly affects children
  • Usually affects popliteal and antecubital fossae, but can occur anywhere
  • Often associated with other atopic conditions, such as asthma, rhinitis and hay fever
  • May have a genetic component


  • Mostly managed in primary care; mainstay is regular emollients
  • Topical steroids often required, depending on severity and location
  • Secondary infection may occur, requiring antibiotics
  • Alternatives to steroids include topical immunosuppressants

Emollient contact dermatitis
Emollient contact dermatitis



  • Rare type of contact dermatitis
  • Can occur due to allergy to lanolin, as in this case
  • Occurs after use of emollients, but may 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


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

Asteatotic eczema
Asteatotic eczema



  • 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


  • 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 Nigel Stollery is a GP in Leicestershire

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