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  • 75-year-old male with R LE rash x 10 months without resolution
  • PCP wants to know best management for venous stasis dermatitis with new ulcer

eConsult Transcript

PCP submission

75-year-old male with R LE rash x 10 months, improved with CeraVe and clobetasol but then returns and now has new smaller lesion on malleolus. Very pruritic. Quantiflo and DPN normal 2019. No other lesions. Known for HTN, hypothyroidism, CKD 3, anemia of chronic disease. Meds =HCTZ, lisinopril, levothyroxine, diclofenac topical knee, Tylenol
For this patient with venous stasis dermatitis and new venous stasis ulcer- what management would you recommend aside from topical moisturizer and topical steroid?

Specialist response

If a patient like this presented to me, these would be my general thoughts: Hi—thanks for the case, history, and photos. I agree with likely venous stasis dermatitis.
1. Nummular dermatitis—which can be notoriously difficult to treat—could be considered as well. As you know, venous stasis dermatitis is often chronic and recurrent, so a waxing-waning course is not unusual.
2. If your patient is experiencing intermittent bouts of lower extremity edema then obtaining lower extremity Doppler ultrasound with subsequent fitting (if not contraindicated) for compression stockings can be useful to consider. The differential also includes dermatophytosis, and even if less likely I would still obtain a scraping of scale to be sent for fungal culture and stain.
3. Otherwise clobetasol 0.05% ointment BID x 4 weeks is a reasonable approach. This can be cycled with Elidel 1% cream (or Protopic 0.1% ointment) BID x 4 weeks in monthly cycles. I would try to add-on urea 10-20% lotion/cream BID standing to help restore epidermal barrier function/integrity and address the scale.
4. I hope this helps—do let me know if you may wish to discuss further. Thank you again for the case.

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