What are the vascular causes of severe edema, swelling, rash, and inflammation in the legs?

From the Guidelines

Severe edema, swelling, rash, and inflammation in the legs are most commonly caused by chronic venous insufficiency, which occurs when damaged valves in leg veins allow blood to pool instead of returning efficiently to the heart, as evident in the most recent study by Rochon et al 1. The causes of these symptoms can be multifactorial, including:

• Chronic venous insufficiency, which may cause varicosities, skin changes, and edema
• Deep vein thrombosis (DVT), a blood clot in a deep vein, leading to sudden swelling, pain, and warmth in one leg
• Lymphedema, resulting from lymphatic system blockage, causing protein-rich fluid accumulation and progressive swelling
• Peripheral artery disease (PAD), reducing blood flow to the legs, leading to pain, skin changes, and tissue damage
• Varicose veins, which can cause skin changes and edema when severe
• Lipodermatosclerosis, a complication of venous disease, causing hardening of the skin and inflammation According to the American Heart Association, the postthrombotic syndrome (PTS) is a common long-term complication of DVT, occurring in a limb previously affected by DVT, and can manifest as a spectrum of symptoms and signs of chronic venous insufficiency 1. Treatment should prioritize compression therapy, leg elevation, and regular exercise to improve circulation, with medications like diuretics or anticoagulants considered based on the underlying cause, as supported by the most recent guidelines 1. Key considerations in management include:
• Compression therapy with 20-30 mmHg graduated compression stockings worn daily
• Leg elevation above heart level several times daily
• Regular exercise to improve circulation
• Medications like diuretics (e.g., furosemide 20-40mg daily) for fluid retention or anticoagulants (e.g., rivaroxaban 15-20mg daily) for DVT
• Procedures to improve venous flow or lymphatic drainage may be necessary in severe cases.

From the Research

Vascular Causes of Severe Edema, Swelling, Rash, and Inflammation in the Legs

The vascular causes of severe edema, swelling, rash, and inflammation in the legs can be attributed to several factors, including:

• Chronic venous insufficiency (CVI), which is characterized by severely impaired blood return that primarily affects veins in the lower extremities 2
• Venous hypertension and reflux due to poorly functioning or incompetent venous valves, leading to a cascade of morphological, physiological, and histologic abnormalities such as blood pooling, hypoxia, inflammation, swelling, skin changes, and venous leg ulcers (VLU) 2, 3
• Deep vein thrombosis (DVT), which can cause acute unilateral lower-extremity edema and requires immediate evaluation with a d-dimer test or compression ultrasonography 4, 5
• Obstructive sleep apnea, which may cause bilateral leg edema even in the absence of pulmonary hypertension 4
• Lymphedema, which can present in one or both lower extremities and is often a clinical diagnosis, with possible secondary causes including tumor, trauma, previous pelvic surgery, inguinal lymphadenectomy, and previous radiation therapy 4, 5

Risk Factors and Associated Conditions

Several risk factors and associated conditions can contribute to the development of vascular causes of severe edema, swelling, rash, and inflammation in the legs, including:

• Age, female gender, positive family history, pregnancy and parity, obesity, prolonged standing, and history of deep vein thrombosis 3
• Medications such as antihypertensives, anti-inflammatory drugs, and hormones, which can contribute to edema 5
• Systemic diseases such as heart failure, which can cause pulmonary edema and require echocardiography to assess cardiac function 5, 6
• Diffuse skin inflammation, which can cause vasodilation and increased vascular permeability, leading to decreased blood pressure and peripheral edema 6