Synopsis
Recognise lower-leg eczema caused by chronic venous hypertension, exclude arterial and acute vascular disease, treat skin inflammation, and coordinate safe compression and venous referral.
- Venous eczema affects the lower gaiter region with itch, scale, oedema, haemosiderin colour, varicosities and sometimes lipodermatosclerosis or ulceration.
- Bilateral chronic itch and scale favour venous inflammation; acute unilateral pain, fever or rapid spread requires assessment for cellulitis or thrombosis.
- Check arterial symptoms and pulses and obtain the locally required vascular assessment before compression; do not prescribe compression blindly.
- NICE recommends vascular-service referral for lower-limb skin changes such as pigmentation or eczema thought caused by chronic venous insufficiency.
- Treat active eczema with daily emollient, soap substitution and a site-appropriate topical corticosteroid while addressing oedema and mobility.
- Compression is a long-term venous treatment when arterial supply and contraindications have been assessed, not merely a dressing for the rash.
- For Venous and gravitational eczema, document body sites, severity, sleep and function, recent treatment, infection features and what the patient can realistically apply each day.
- In Venous and gravitational eczema, reassess the diagnosis when a well-used, correctly potent regimen fails rather than repeatedly intensifying treatment without examining adherence, exposure and mimics.
Key red flags
Sudden unilateral swelling, chest symptoms, rest pain, cold foot, absent pulses, fever, rapidly increasing erythema, severe ulcer pain or uncontrolled bleeding requires urgent vascular or medical assessment.
Sudden one-sided swelling, calf pain, cold foot, rest pain, absent pulse or chest symptoms needs urgent assessment.
Investigation priorities
Identify arterial compromise or acute vascular threat before compression.
Management branches
Chronic gaiter eczema and oedema occur without acute arterial, thrombotic or infectious red flags.
- Use leave-on emollient daily as cleanser and moisturiser and a defined course of topical corticosteroid only on actively inflamed patches.
- Encourage walking, calf activation and periods of leg elevation while reducing prolonged dependent sitting or standing where feasible.
- Assess arterial supply, then introduce correctly fitted compression through the appropriate trained service and review tolerance.
Key medicines
Betamethasone valerate 0.1% creamApply thinly to active intact lower-leg eczema once or twice daily for up to four weeks, then reduce or stop when inflammation is controlled.Avoid ulcer beds, untreated infection, large denuded areas and unplanned occlusion; review atrophy and contact sensitivity and do not mistake haemosiderin pigment for active disease.