This document discusses venous eczema and the prescriber's role in its diagnosis and treatment. It covers the pathophysiology of venous disease, clinical diagnosis using the CEAP classification system, and treatment approaches including topical steroids and emollients to treat inflammation, potassium permanganate soaks for infection, compression therapy, and lifestyle changes. The key roles of the nurse prescriber are to clinically diagnose venous eczema, treat symptoms like infection or itching, refer patients for treatment of underlying varicose veins as needed, educate on health promotion, and address quality of life issues to help patients effectively manage their condition.

1. Venous Eczema – the prescriber’s role
Linda Nazarko
MSc, PgDip, PgCert, BSc(Hons), RN, NIP, OBE, FRCN
Consultant Nurse West London Mental Health Trust
Nurse Prescribing for Wound Care, ICO London
19 January 2016
,

2. Aims and objectives
To be aware of:
 Pathophysiology of venous disease
 Principles of diagnosis and treatment
 Diagnosis & treatment of venous eczema
 Diagnosis & treatment of infected venous
eczema
 The topical steroids in managing flare ups,
 The role of emollient therapy
 Compression in maintaining skin health and
comfort
 The value of the nurse practicing at advanced
level.

3. Venous disease -pathophysiology
 Elevated venous pressure stretches and
damages valves
 Valves fail, venous hypertension results
 Increased pressure superficial veins and
capillaries

4. Prevalence & pre-disposing factors
Venous disease affects 1/3 of adults. Predisposing
factors:
 Abdominal tumour
 Ageing
 Obesity
 Pregnancy
 DVT

5. Ageing and the need for emollients
Change Consequence
Skin thins More easily damaged, increase risk of bruising
and skin tears
Replacement rate
slows
Takes longer to heal
Reduced
melanocytes
Burns more easily
Loss of collagen Saggy wrinkly skin
Increased risk of skin tears, increased healing
time, wounds more prone to breaking down
Loss of fat Prominent veins, increased risk of bruising
Reduced protective layer, increased risk of skin
damage, increased risk of pressure sores.
Loss of lipids and
water
Dry skin, cracks easily
Increased risk of infection

6. What is venous eczema?
 “A non infective inflammatory condition
that affects the skin of the lower legs”
(Gawkrodger, 2006).

7. Clinical Etiological Anatomical
Pathological (CEAP) classification
C0 No visible or palpable signs of venous disease
C1 Telangiectasies (spider veins) or reticular veins
C2 Varicose veins, distinguished from reticular
veins by a diameter of 3mm or more.
C3 Oedema
C4 Changes in skin and subcutaneous tissue
secondary to chronic venous disease, divided
into 2 sub-classes to better define the differing
severity of venous disease:
C4a Pigmentation or eczema
C4b Lipodermatosclerosis or atrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer

8. Principles of diagnosis and treatment
•This is a clinical diagnosisDiagnose venous eczema
•Assess and treat symptoms, e.g infection, weeping,
scale, red inflammed skin
Treat eczema
•Assess and check if safe to apply compression. If no
contraindications apply compression
Treat swelling
•Obtain consent and refer for treatmentRefer for treatment of varicose
veins
•Advise on weight management, standing, walking,
elevation and leg crossing
Health promotion
•Treat any issues affecting quality of life that have not
been addressed such as pain
Quality of life

9. Diagnosis of venous eczema
 Clinical diagnosis, use CEAP classification,
observe for stigmata of venous disease
 Can lead to dry, thickened, scaly, cracked
skin & can easily become infected

10. Diagnosis of infected venous eczema
 Check clinical
features venous
disease
 Check features of
infection
 Check bloods, FBC,
CRP, U&E
 Wound swab

11. Treatment of infected venous
eczema
 If systemic infection treat antibiotic therapy –
local formulary usually flucloxacillin 500mg
QDS if not penicillin allergic. Erythromycin or
clindamycin if allergic.
 Skin cleansing and debridment
 Potassium permanganate soaks weeping
eczema
 Topically steroids and emollients

12. Potassium permanganate
 Astringent and antiseptic properties
 One tablet in 4 litres water = 1:10,000 solution on average 4
tablets her bucket. Line the bucket. Soak 10-15 minutes
 Use soft paraffin on nails to prevent staining
 Use for 3-5 days once or twice daily
 Store carefully ingestion can cause death through toxicity and
organ failure

13. Infected venous eczema before &
after ten days treatment

14. Treating red itchy inflamed
skin -steroid therapy
 Eczema is a chronic inflammatory skin condition. The
skin becomes red, inflamed, itchy and scaly (Steen,
2007: Holden & Berth-Jones, 2004).
 There are three stages of eczema:
1. Acute (when there is oozing, with tiny fluid filled
lesions and swelling)
2. Subacute (scaly and red)
3. Chronic (thick and hyperpigmented skin
 Steroids can be used in acute and subacute stages.

15. Use of steroid therapy
 Topical steroids
classified according to
potency
 All (other than mild) can
be used daily
 Use for 14 days early
discontinuation =
relapse
 Don’t use long term –
thins skin
 Use emollient therapy
afterwards

16. Tips for prescribing and administering steroids
 The fingertip unit (FTU) is
0.5g of ointment and an adult
lower leg requires three FTUs.
 Use moderately potent and
potent steroids
 Apply steroids, leave to absorb
and apply emollients 15-30
minutes after

17. Treating scale and lichenification
 Remove hyperkeratotic skin using
Debrisoft pad or UCS debridement
cloth
 Single treatment or 3-4 treatments

18. Why emollients are required
 Asteotic element to venous eczema,
skin is dry
 Lipids restore normal barrier function
and stop itching
 Reduces infection risk and flare ups

19. CKS guidance on emollients
Consideration Recommendation
Dryness of skin Mild to moderately dry use creams
Moderate to severely dry – use ointments
Weeping dermatitis Use creams as ointments will tend to slide off,
becoming unacceptably messy.
Frequency of
application
Creams are better tolerated but need to be applied
more frequently and generously to have the same
effect as a single application of ointment.
Choice and
acceptability
Take account of the individual's preference,
determined by the product's tolerability and
convenience of use.
Efficacy and
acceptance
Only a trial of treatment can determine if the
individual finds a produce tolerable and convenient
One size does not fit
all
More than one kind of product may be required.
The intensity of treatment required and the area to
be treated should guide treatment choice.
Balancing
acceptability and
effectiveness
The individual (and the prescriber) need to balance
the effectiveness, tolerability and convenience of a
product

20. Guide to emollients

21. Tips on emollient prescribing
 Be generous – an adult can require 500g of
emollient a week
 Tailor prescribing to patient preference and
ability to apply.
 Beware of emollients containing lanolin – can
cause sensitivity
 Consider emollients with urea if skin unbroken
 Be aware that patients can react to creams so
monitor effect and change if concerns

22. Refer for treatment
 NICE guidance (2013) states that those
with venous disease should be referred
for assessment and treatment.
 Treatments include endothermal
ablation, endovenous laser treatment of
the long saphenous vein ultrasound
guided foam sclerotherapy and surgery.

23. Treat the swelling
 Compression bandages if
severe
 Compression stockings
when settled
 Elevate feet – higher
than hip
 Elevate foot of bed

24. Benefits of compression
 Reduces venous hypertension
 Reduces swelling
 Prevents ulceration
 Improves healing rates when
ulceration occurs
 Improves comfort

25. NICE recommendations on
compression
‘Do not offer compression hosiery
to treat varicose veins unless
interventional treatment is
unsuitable.’
But: Patient may decline or not
be well enough for surgery.

26. Bandages or stockings – the evidence
 Mobile patients with highly exuding ulcers
may require three or four layer bandaging
(NICE, 2015: SIGN, 2010)
 In all other cases two layer compression
stockings are as effective as four layer
compression bandaging (Ashby et al, 2013)
 Its important to consult the patient and
ensure that compression method meets his or
her needs and aspirations

27. Assessment prior to compression
 Check for contraindications e.g severe
heart failure
 Doppler ultrasound to check
compression will not lead to
compromised circulation
 Check condition of skin and debride if
necessary

28. Hosiery selection
Consult the patient
 Thick, ribbed & sock like, for men and some
ladies
 Below knee
 Above knee
 Open and closed toe
 Get the colour right
 Grade two that is worn is better than grade
three that isn’t.

29. Health promotion
 Promote health
 Weight loss if overweight
 Don’t stand around for long periods
 Activity - walking
 Don’t cross legs
 Don’t wear pop socks or socks that are
tight at the top

30. Maintaining healthy skin
 Use emollients
 Protect skin from knocks
 Don’t smoke
 Protect skin from sun damage
 Maintain good nutrition
 Maintain hydration
 Maintain health

31. Quality of life
 Venous disease can be horrible. The
person may have dry itchy skin,
weeping, infection, exudate, odour and
swollen aching throbbing legs.
 A structured approach to management
and treatment should address these
issues but check.
 Address unresolved issues or refer

32. The value of advanced nursing practice
 Enables and empowers
person to experience
best possible quality of
life.
 Treats problems
promptly
 Prevents complications
 Enriches the lives of
those we care for and
our lives

33. Key points
 Venous disease is common in adults
 The prevalence of venous disease rises with
age
 Changes caused by venous disease can lead to
pain, discomfort and deteriorating health
 Lifestyle changes can improve well-being
 Effective management can treat complications
and improve comfort.
 You can make a difference so use your
diagnostic & prescribing skills.

34. Thank you for listening
Any questions?