Dermatitis – dry and itchy skin

Overview – dermatitis is a general term that describes a common skin irritation

Our lower legs can sometimes get inflamed or itchy. This is known as dermatitis.

Causes – what causes dermatitis / dry, itchy skin?

Dermatitis on the lower legs can often be caused by eczema. Eczema is a common skin condition that comes in many forms and affects people of all ages. It’s not contagious, so you can’t catch it from someone else.

Contact eczema / dermatitis

Contact eczema / dermatitis accounts for 70-90% of all occupational skin disease. It is an iflammatory skin condition caused by external irritants such as body lotions and creams, or by clothing that contains wool.

Atopic eczema / dermatitis

Atopic eczema is more common in children but you can also develop it for the first time as an adult.  It is not clear what causes atopic eczema but it often occurs in people who have allergies.

Varicose eczema / dermatitis

Varicose eczema happens when high pressure in the veins in the legs pushes our blood into the skin tissue. This causes irritation. Varicose eczema is usually red and very itchy with scaly patches. Sometimes you may have patches that are also weeping or notice reddish brown staining above your ankle. Varicose eczema can be itchy and you are advised not to scratch and this can exacerbate the itchiness and damage or break the skin.

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.

Diagnosis – getting diagnosed with dermatitis

If you have dry, itchy or scaly skin on your legs, make an appointment at your GP practice. You may be given an appointment to see the nurse rather than the doctor as nurses are often responsible for caring for patients with leg problems

Alternatively, there might be a Leg Club or specialist leg clinic in your area. You don’t need to be referred by your GP to attend one of these.

When you see the nurse or doctor, they should look for:

• Changes to the elasticity of the skin
• Skin fissures or scratches
• Itching (pruritis)
• Dry skin (xerosis)
• Blisters
• Pustules
• Red / inflamed skin
• Weeping / crusty lesions

Other signs that might be present include:

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

If it looks like you have varicose eczema, you may be provided with a mild compression sock and given and appointment for a simple test called a Doppler ultrasound. This test compares blood flow in your ankle with that in your arm to find out if there are blood flow problems in your lower leg. You might have to come back to have your Doppler test on another day or at another clinic but you should have this test within a few weeks of your first appointment.

• If you appear to have problems with your veins or arteries, you should be referred for further vascular tests
• If you have secondary spread or weeping eczema, you should be referred to a Dermatologist for advice

You may also wish to visit your local pharmacy in the first instance and speak to a pharmacist who may be able to assist.

Treatment – what treatment will I be offered for dermatitis?

If you have any form of eczema, the most important thing is to keep your skin clean and well moisturised. Avoid soap and washing with hot water as this can dry the skin and cause irritation, use warm water. Use a moisturising soap substitute when washing, bathing and showering.

After washing gently dry the skin avoiding excessive rubbing to reduce friction and irritation. Ensure the skin is fully dry before applying a moisturiser (also known as an emollient) paying particular attention to in between the toes. Applying the moisturiser in a downward motion not against the hair growth can help prevent irritation of the hair follicle from the moisturiser. Allow the moisturiser to soak in for a time before applying clothes or undergarments as this will help optimise absorption.

Always moisturise your skin after washing, bathing and showering preferably using a unperfumed emollient. If you’re using moisturisers in the bath or shower, remember to also use a rubber mat or grip rail as the bathtub can become very slippery.

Sometimes, your skin may need more than just a moisturiser. Your doctor or nurse may recommend a steroid ointment or cream to be applied to the areas of eczema.

If you have varicose eczema, compression therapy can also help improve your blood flow and ease varicose eczema.

Compression therapy

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

Topical steroids

Topical steroids (provided as a cream or ointment) are powerful anti-inflammatories and are likely to be helpful. Potent steroid ointment can be applied to affected areas (daily or at dressing changes if a wound is present). Your Nurse or Doctor will advise you on what strength steroid is required, how often to apply, and how much to apply. Daily application is preferred in the first two weeks and then this is usually reduced gradually. When steroid creams or ointments are used underneath compression therapy, frequency of use is less; seek advice on amount and duration.

Where’s the harm?

• It is unlikely that varicose eczema will resolve without compression therapy, good skin hygiene with emollient and often topical steroids
• Left untreated, varicose eczema can worsen and is at risk of becoming infected
• If you have eczema or dermatitis on your legs ask your health professional if it is varicose eczema (not all dermatitis on legs is varicose eczema)  if it is, you need to be offered the treatments above

Suggested resources

• Fact sheets from the National Eczema Society (Web page)

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

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