Venous Eczema

Venous Eczema is the name given to the rough and itchy skin, often pink or red, that can be found on the legs in some people. It is usually found around the ankles or lower legs and is caused by varicose veins and venous reflux (hidden varicose veins). Although people with varicose veins can usually see them, people with venous reflux (hidden varicose veins) have the same problem with their veins but do not know that they have it, as the veins are hidden deep under the skin.

The most important thing to know about venous eczema is that it is totally curable provided that is treated correctly by an expert in varicose veins and venous disease – such as the experts at The Whiteley Clinic who follow The Whiteley Protocol®.

Traditional treatments including creams and support stockings temporarily help improve Venous Eczema, but actually do nothing to the underlying cause. If the underlying cause isn’t treated properly, the venous eczema usually progresses. This progression can lead to a worsening of the Venous Eczema, or further skin damage or even to leg ulceration.

Causes of Venous Eczema

Venous Eczema occurs only after many years of inflammation due to venous reflux.

Research performed by Mark Whiteley, in Reading in the 1990s, showed that 1 in 20 schoolchildren aged 9 had venous reflux already, and 1 in 9 of schoolchildren aged 18 had venous reflux – although virtually none of them had any varicose veins visible on the surface.

Therefore the underlying venous problem that can cause Venous Eczema starts very early in life – and so it is possible that Venous Eczema can also appear fairly early in life. However, due to the time it takes to develop, it is rarely seen in the under 20s but it is more common the older the person becomes.

Hidden Varicose Veins

In the adult population, about 1 in 4 people have varicose veins. As there are many people who have venous reflux without visible varicose veins (‘hidden varicose veins’) the number of people at risk from Venous Eczema is even higher.

As Venous Eczema is curable and preventable, no one should actually have it at all. If people insisted on seeing venous experts and having treatments such as those provided by The Whiteley Protocol®, then anyone with Venous Eczema could be cured and virtually anyone coming with any venous problems before the Venous Eczema developed could have the Venous Eczema prevented.

Therefore in any population where it is common, it shows that there is a lack of people having proper diagnosis, investigation and treatment.

Unfortunately there is a general lack of understanding about varicose veins and venous reflux disease. Most people (and many doctors and nurses) only diagnose varicose veins if they can see bulging veins on the surface – and if they do see them, they usually dismiss them as “only cosmetic”. Both of these responses are usually wrong.

To understand varicose veins and venous reflux fully is difficult – hence the huge amount of research that has gone into the development of The Whiteley Protocol® for treating venous problems. However, the underlying principles can be made simpler.

Blood gets pumped from the heart into the legs to keep the tissues oxygenated and supplied with nutrients. Once the blood has got to the feet and lower legs, it has to be pumped back up the legs to the heart. When lying down, this isn’t a problem. However, when we are standing up or sitting down, the feet and ankles are below the heart. Therefore, to get the blood back to the heart it needs to be pumped up the veins against gravity.

The pumping of the blood is achieved by contraction of the leg muscles which push on the veins, forcing the blood up the veins. When the muscles relax, the blood could fall back with gravity if it wasn’t for the valves inside the veins. When the blood starts to flow back down the veins, valves flap open from the vein wall, holding the blood where it is. On the next muscle contraction, more blood is forced up the vein, opening the valve and carrying the blood further upwards on its way to the heart.

In people with varicose veins or venous reflux (hidden varicose veins) valves in some of the veins stop working. In these people, the muscle contraction and pumping is normal. However, when the muscles relax, the blood falls down the vein that has lost the valves, hitting the small veins and capillaries at the bottom of the vein and causing inflammation.

In some people, the body reacts to try to stop the inflammation by dilating side veins. In these patients, the blood falling down the main vein gets side-tracked into the dilated side veins which act as ‘shock absorbers’ reducing the impact of the blood on the small veins at the lower leg and therefore reducing the inflammation. These dilated side veins can sometimes be seen bulging under the skin – these are ‘varicose veins’.

However, in other people, the body doesn’t open up side branches. In these people the blood falls down the vein without anything to stop it, causing inflammation at the bottom of the vein. In these people there are no visible varicose veins on the surface and so patients, doctors and nurses often say that the patient doesn’t have ‘varicose veins’! However the underlying problem of the valves not working and the inflammation that is caused by the blood ‘refluxing’ down the vein the wrong way is the same! This is why we call this problem ‘venous reflux’ or ‘hidden varicose veins’.

The inflammation that is caused by the venous reflux – both in people who have visible varicose veins as well in those who have ‘hidden’ varicose veins – affects the small veins at the point where the falling blood hits them. This is usually at the bottom of the leg, around the ankle. At first the inflammation is deep inside and so it is not noticed. With time, if the veins aren’t treated, the inflammation continues and so starts to spread outwards, towards the skin surface.

At this stage people will often notice some swelling of the ankles or aching of the leg, both caused by the deep but spreading inflammation. Unfortunately, if varicose veins aren’t visible on the surface, these signs are often ignored or mis-diagnosed and the opportunity to cure the problem is missed.

As the inflammation spreads outwards through the deep tissues of the lower leg, it causes some irritation of the deep layer of the skin. This makes the person with the problem start to rub and scratch the leg – often without noticing that they are doing so. Over time, repeated scratching and rubbing damages the skin surface causing an inflammation of the skin itself. This is called Eczema

The fact that the underlying cause of the eczema is the venous reflux is the reason it is called ‘Venous Eczema’.

If you have followed the above sequence and have understood it, then the treatments become clear and obvious – as do the things that you should avoid.

Symptoms of Venous Eczema

In order to recognise Venous Eczema, the first thing is to think of it. Any patch of red or roughed or itchy skin on the lower leg or legs might be a symptom of Venous Eczema. It is usually around the ankle or lower leg, due to the fact that the blood falling or ‘refluxing’ down the veins without valves, usually hits this area. Sometimes, especially if there is a very big varicose vein near the surface, a patch of Venous Eczema can appear either directly over or very close to the varicose vein – which might even be on the thigh.

In a great many people, the eczema is seen but the veins are not (see the section on ‘hidden varicose veins’ above). Therefore, if you can’t see varicose veins, it doesn’t mean that it isn’t Venous Eczema.

If the patch of eczema is over the knee, then it is less likely to be Venous Eczema. If there are patches of eczema elsewhere on the body, especially on the arms or scalp, then the patches on the legs are less likely to be a venous cause. However, they might be – as venous reflux is such a common problem.

What should you do if you have Venous Eczema?

If you have, or think that you might have, Venous Eczema you need to be assessed by a venous expert such as the experts at The Whiteley Clinic. You should probably go to your GP first, but you should not allow yourself to be side-tracked into ineffective or temporary treatments such as steroid creams or support stockings (see below).

Everybody who either has Venous Eczema, or who might have Venous Eczema, needs to have a specialised venous duplex ultrasound performed by an experienced vascular scientist. Many people perform venous duplex ultrasound examinations, but only a few do these regularly most days of every week. It is essential to have a venous duplex ultrasound performed not only by someone who is trained, but who spends the majority of their time scanning veins. At The Whiteley Clinic we ensure that all of our Vascular Scientists are trained to the level required by The Whiteley Protocol® and have regular venous work keeping their skills honed.

It is acceptable to have support stockings or steroid creams in the short term provided they are only used to relieve the symptoms whilst the referral to a venous specialist and a venous duplex ultrasound is arranged.

How is venous eczema treated?

The principle of treatment is easy. As Venous Eczema is caused by blood refluxing the wrong way down the veins that don’t have valves working in them, then stopping this venous reflux cures the condition.

In the past, surgeons used to stop the blood falling down these veins by tying the veins and stripping them away under a general anaesthetic. However, this has shown to be a bad idea as it is painful, destructive and the veins only grow back again in the majority of patients.

Since Mark Whiteley brought keyhole surgery for varicose veins into the UK in March 1999, the optimal treatments for venous reflux are combinations of keyhole methods.

It is both the wide choice of techniques that are now available and the fact that different veins are optimally treated by different combinations of these techniques that makes the treatment choice more difficult.

Fortunately, Mark Whiteley from The Whiteley Clinic developed The Whiteley Protocol® which directs the experts at The Whiteley Clinic to use the optimal combination of treatment options for the venous reflux pattern that is found in patients.

Therefore, the exact treatment each patient needs is tailored individually for them, using The Whiteley Protocol® – making sure that when treatment is finished, there is no blood refluxing down any veins in the pelvis or leg, stopping any inflammation and therefore letting the Venous Eczema heal.

What treatments to avoid

Traditionally Venous Eczema has been treated by a variety of creams (usually steroid), anti- histamines and / or support stockings (or more correctly ‘Graduated Pressure Stockings’).

The steroid creams and anti-histamines are used to try to calm the inflammation in the skin. However, as the inflammation in the skin is caused by the inflammation coming from more deeply – which is caused by venous reflux and the impact of the blood falling down veins in which the valves have failed) – calming the inflammation in the skin alone is illogical.

It may help the skin to feel better in the short term, but the underlying reflux and inflammation will continue to worsen, leading to a worsening of the condition despite the skin feeling better. As this worsening can result in clots in the veins (phlebitis), bleeding or leg ulceration, then hiding the eczema away by steroid creams or anti-histamines is not a good idea.

Of course these can be used, provided that they are only prescribed for symptomatic relief whilst the patient is referred for specialist investigation and treatment.

In the case of support stockings, the pressure of the stocking on the skin is transmitted into the veins deep within the leg. This raises the pressure in the lower leg, reducing the flow of blood refluxing (or ‘falling’) back down the veins with non-working valves.

As the venous reflux is reduced, the inflammation is reduced and so the Venous Eczema either improves a little or is held stable.

Of course, as nothing has been done to the underlying veins themselves, as soon as the support stockings are removed the problem continues as if nothing has happened.