What is the diagnosis and treatment for a 73-year-old female with stasis (venous stasis) dermatitis, chafing, and xerosis (dry skin) of the heels, presenting with pruritus (itchiness)?

From the Guidelines

For a 73-year-old female with stasis dermatitis, chafing, and dry, itchy heels, I recommend a multi-faceted treatment approach that prioritizes the use of gentle cleansers, emollients, and compression therapy to address the underlying venous insufficiency and skin barrier dysfunction. To start, a gentle cleanser like Cetaphil or CeraVe should be used, avoiding hot water and harsh soaps, as recommended by general dermatological principles 1. Key components of the treatment regimen include:

• Applying a thick emollient like petrolatum (Vaseline) or Eucerin cream to lock in moisture, applying at least twice daily, especially after bathing while skin is still damp
• Using a urea-containing cream (10-20%) like Eucerin Roughness Relief or AmLactin to help soften thickened skin on the heels
• Wearing compression stockings (20-30 mmHg) during the day to improve venous return and reduce edema that contributes to stasis dermatitis
• Elevating legs when sitting or lying down to reduce swelling
• Avoiding scratching and wearing cotton socks to reduce friction Although topical corticosteroids may be considered for reducing inflammation and itching, their use should be approached with caution due to potential side effects, such as perioral dermatitis and skin atrophy, especially in elderly patients 1. Additionally, treatments that should be avoided include greasy creams for basic care, manipulation of skin, hot blow-drying of the hair, wearing of tight shoes, and topical acne medications, as they may exacerbate the condition or increase the risk of infection 1. It is essential to note that the provided study from 2002 1 focuses on the diagnosis and treatment of heel pain, which is not directly relevant to the treatment of stasis dermatitis, chafing, and dry, itchy heels. Therefore, the treatment approach should be guided by the more relevant and recent study from 2011 1, which provides recommendations for the management of skin reactions, including the treatment of xerotic and eczematous skin, pruritus, and fissures.

From the FDA Drug Label

Indications and Usage For debridement and promotion of normal healing of hyperkeratotic surface lesions, particularly where healing is retarded by local infection, necrotic tissue, fibrinous or purulent debris or eschar. Urea is useful for the treatment of hyperkeratotic conditions such as dry, rough skin, dermatitis, psoriasis, xerosis, ichthyosis, eczema, keratosis pilaris, keratosis palmaris, keratoderma, corns and calluses, as well as damaged, ingrown and devitalized nails. Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily Purpose Anti-itch

The diagnosis for the 73-year-old female is stasis dermatitis with xerosis (dry skin) and pruritus (itchiness) of the heels. The treatment options include:

• Urea (TOP) for the treatment of hyperkeratotic conditions such as dry, rough skin, dermatitis, and xerosis 2
• Hydrocortisone (TOP) for itching of skin irritation, inflammation, and rashes, and as an anti-itch agent 3 3

From the Research

Diagnosis of Stasis Dermatitis

The diagnosis of stasis dermatitis can be challenging due to its clinical resemblance to other skin conditions and poor clinical recognition by physicians 4. The condition typically occurs in older individuals and is the cutaneous manifestation of venous hypertension caused by venous reflux. Key characteristics include:

• Eczenatous skin changes
• Impairment of venous valves causing swelling of the legs
• Potential for serious conditions including venous ulcerations

Treatment of Stasis Dermatitis

The cornerstones of stasis dermatitis treatment are:

• Compression therapy to ameliorate pain and swelling
• Topical treatments to alleviate secondary skin changes
• Interventional treatment options to correct the underlying causes of venous reflux 4 Some studies suggest that topical tacrolimus may be an effective treatment for stasis dermatitis, providing anti-inflammatory and antipruritic effects 5.

Management of Associated Conditions

For patients presenting with pruritus, chafing, and xerosis, management may involve:

• Topical treatments to alleviate dry skin and itchiness
• Measures to reduce friction and prevent further irritation
• Consideration of underlying causes of venous insufficiency, such as chronic occlusion of veins or inferior vena cava filter occlusion, which may require referral to an interventional radiologist 6

Considerations for Contact Dermatitis

In patients with stasis dermatitis, there is a high risk of developing allergies to ingredients of topical treatments, dressings, and bandages 7. If allergic contact dermatitis is suspected, patch testing should be considered, and age should not be a deterrent to this diagnostic approach. Accurate diagnosis, avoidance of identified allergens, and protection from irritants are key to successful treatment.