What is the diagnosis and treatment for a 3-month progressive, inflamed, patchy, and intensely pruritic (itchy) rash on both legs, worsening with prolonged standing, occasionally oozing pus, in a patient with no prior similar rashes or medication use?

Diagnosis: Stasis Dermatitis (Venous Eczema)

This is stasis dermatitis secondary to chronic venous insufficiency, characterized by the progressive, pruritic, inflamed rash on both legs that worsens with prolonged standing and produces serous (not purulent) drainage. 1

Clinical Reasoning

The key diagnostic features pointing to stasis dermatitis include:

• Bilateral lower extremity involvement with asymmetric severity (one leg worse than the other) 1
• Worsening with prolonged standing due to increased venous pressure and impaired drainage 1
• Progressive course over 3 months consistent with chronic venous disease 1
• Intense pruritus is a hallmark symptom of venous eczema 1, 2
• Oozing fluid (likely serous exudate, not true pus) from inflamed, weeping eczematous patches 2

The patient likely has underlying venous insufficiency with incompetent valves and increased intravenous pressure, leading to inflammatory skin changes. 1 Risk factors include prolonged standing, which this patient clearly experiences. 1

Immediate Treatment Algorithm

First-Line Topical Therapy

• Apply high-potency topical corticosteroid such as clobetasol propionate 0.05% or betamethasone valerate 0.1% to affected areas twice daily for 2-4 weeks maximum 3, 2
• Liberal application of emollients multiple times daily to all affected areas to restore skin barrier function 4, 3
• Oral antihistamines for pruritus control: cetirizine 10 mg daily or loratadine 10 mg daily for daytime relief 4, 3
• For severe nocturnal itching, add hydroxyzine 25-50 mg or diphenhydramine 25-50 mg at bedtime 3

Critical Pitfall Warning

Do not use high-potency corticosteroids continuously beyond 4 weeks due to risk of skin atrophy, striae, and HPA axis suppression. 3 After initial control, transition to lower-potency maintenance therapy or alternative agents. 3

Alternative Agent

• Topical tacrolimus 0.1% ointment can be used as an alternative or after initial corticosteroid course, applied twice daily, particularly effective for stasis dermatitis without the atrophy risks of steroids 4, 2

Definitive Management: Compression Therapy

The cornerstone of long-term management is compression therapy to address the underlying venous insufficiency. 1, 2 However, acute weeping dermatitis must be controlled first with topical therapy before initiating compression. 2

• Once acute inflammation subsides, initiate graduated compression stockings (20-30 mmHg) 1
• Avoid prolonged standing and elevate legs when possible 1
• Weight loss if applicable 1

Referral for Definitive Treatment

Refer to vascular surgery or interventional radiology for evaluation of endovenous thermal ablation, which has largely replaced surgery as the standard of care and can be performed under local anesthesia with better outcomes than compression alone. 1 While some insurance may require a trial of compression therapy first, current evidence suggests this is not medically necessary before referral. 1

Rule Out Infection

If true purulent drainage is present (thick, yellow-green pus rather than clear serous fluid), obtain bacterial culture before intensifying corticosteroid therapy, as steroids can worsen bacterial infection. 3 The description of "oozing pus" may actually represent serous exudate from acute eczema, which is common in stasis dermatitis. 2

What NOT to Do

• Avoid calamine lotion, crotamiton cream, or topical capsaicin as they lack proven efficacy for this condition 3
• Do not apply compression wraps over acutely inflamed, weeping skin until inflammation is controlled 2
• Avoid harsh soaps and irritants that can worsen the dermatitis 3