Bilateral cellulitis on legs? think venous stasis dermatitis

If a patient present with cellulitis on both legs, think venous stasis dermatitis, which is the no. 1 misdiagnosis of cellulitis and a frequent cause of unnecessary hospitalization for so-called “red leg” as said at the UCSF Annual Advances in Internal Medicine meeting. It is easy to make that mistake, because you have a red, hot leg that’s painful, and the patient is having difficulty walking. Venous stasis dermatitis is one of the things you want to learn to recognize, as hospitalization is typically not needed.

The condition can appear red or edematous, but venous stasis dermatitis almost always present bilaterally. Usually the left leg is more edematous, compared with the right leg. That has to do with the venous return back to the heart, according to a dermatologist at UCSF Medical Center. It is unilateral, it’s almost always on the left side.

Patients often have features of venous insufficiency that cause stasis, including varicose veins and brawny hyperpigmentation on the medical aspects of the ankles. They have almost no systemic features, no fever, no white count, no lymphadenopathy. These patients need some kind of anti-inflammatory medication because the skin is very inflamed. If you happened to take a biopsy, you would see inflammation as well as lymphatic congestion. It is recommended that patients apply a midpotency topical steroid such as triamcinolone to the affected area, followed by compression, ideally antiembolism stocking (TED hose) – but that can be a hard sell.

When your legs are that swollen, they’re really painful to wear. Patients will say, “Don’t you come near me with those TED hose.” If you’re in that situation, tell them to use an Ace wrap with light compression and each day tighten the Ace wrap a little more until they are able to use TED hose with minimal discomfort.

The differential diagnosis for venous stasis dermatitis includes cellulitis (which rarely presents bilaterally), deep vein thrombosis, asteatotic dermatitis, erysipelas (more superficial cellulitis that results in elevated, shiny plaques), pyomyositis, necrotizing fascilitis, leukocytoclastic vasculiotis and allergic contact dermatitis.