Patients with dry and itchy skin – dermatitis

Dry, itchy skin on the lower legs is often associated with venous disease / venous hypertension, which is also known as venous eczema, varicose eczema or gravitational dermatitis.

Causes of dry and itchy skin

Prolonged high pressure in the lower limb veins results in chronic inflammatory skin changes. Your patient might present with:

• ‘Red legs’ (commonly confused with cellulitis)
• Dry itchy skin
• Small discrete patches of skin plaques or, at its most severe
• More widespread and circumferential areas of inflammatory blistered and wet lesions.

Further complications can occur from venous eczema.

Cellulitis – There may be a spreading redness in the limb, swelling, pain, heat, pyrexia. The patient may be feeling unwell.

Skin infection – Local infection presenting as yellow pustules and/or crusts. This is often associated with staphlococcus aureus.

Contact dermatitis – It is possible that contact dermatitis can arise from reactions to treatments for venous eczema such as reactions to dressings or creams.

Assessment of a patient with dry and itchy skin

You should make a clinical diagnosis based on appearance and associated features. This should form part of your comprehensive  lower limb assessment that will look for the presence of venous disease.

Look for:

• Changes to the elasticity of the skin
• Skin fissures or scratches
• Pruritis (Itch)
• Xerosis (Dry skin)
• Blisters
• Pustules
• Red / inflamed skin
• Weeping / crusty lesions

Other signs that may be present include:

• Oedema
• Haemosiderin staining / hyperpigmentation
• Atrophie blanche
• Ankle flare
• Varicose veins
• Skin ulceration

Your assessment should include:

• Wounds Essentials 6: Skin Care: Eczema and dermatitis of the lower legs – Wounds UK (Web page with pdf download)
• Doppler ultrasound to record an Ankle Brachial Pressure Index (ABPI). This test screens for clinically significant arterial impairment.
  World Wide Wounds (Web page)
  Nursing Times – Doppler assessment (Web page)
• If your patient appears to have problems with their veins or arteries, you should refer them for further vascular tests.
• If your patient has secondary spread or weeping eczema, you should refer them to a Dermatologist for advice.
• If your patient appears to have problems with their veins or arteries, you should refer them for further vascular tests .

Treatment for dry and itchy skin

Compression therapy

For wet or dry eczema caused by venous hypertension it is important that you treat the underlying cause. The most effective treatment for venous insufficiency is compression therapy.

Further information:

Sores and knocks which are not healing (Web page)

NICE – venous eczema and lipodermatosclerosis (Web page)

Wounds UK – compression hosiery  (PDF Download – Open access – registration required to download)

NICE – compression stockings (Web page)

Topical steroids

Topical steroids are likely to be helpful. Potent steroid ointment can be applied to affected areas (daily or at dressing changes if a wound is present). Daily application should only be for maximum of 2 weeks. After this, reduce potency of steroid ointment and continue for a further 2 weeks. When steroid creams or ointments are used underneath compression therapy, frequency of use is less; seek advice on amount and duration.

Emollients

You should encourage people with eczema to use emollient based soap substitutes for washing their legs and to apply emollient creams daily to improve the strength of the skin barrier.

Fragranced products and factors that increase skin damage (such as heat and sun UV rays) should be avoided.

Publications & Evidence for dry and itchy skin

We’ve carefully curated resources to help in your everyday work.

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Patient information for dry and itchy skin

The patients, family and friends section has lots of useful, accessible information for your patients.

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Clinical guidelines for dry and itchy skin

These guidelines will give you  a useful overview and more detailed information about venous eczema management:

• The NICE Clinical Knowledge Summary on venous eczema (Web page)
• A Patient Profession Reference article on venous eczema (Web page)

Dowload a patient information leaflet as a pdf to print