A Young Man With Pruritic, Hyperpigmented Scales on His Arm

AUTHOR:
Riley J. Burke, DO

CITATION:
Burke RJ. A young man with pruritic, hyperpigmented scales on his arm. Consultant. 2016;56(11):1001.

DISCLOSURE: 
The opinions and assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the US Air Force Medical Department or the US Air Force at large.

A 23-year-old man presented with a pruritic rash on his right upper arm that had first appeared 3 weeks ago. He reported dry, flaky skin and associated pruritus throughout the right upper arm.

His history was significant for deep venous thrombosis of the right axillary and brachial veins 3 months prior, and for factor V Leiden.

On physical examination, multiple hyperpigmented papules with scaling were present over the lateral aspect of the right upper arm. The lesions were nonblanchable and nontender. Superficial varicosities and mild edema were present along the medial aspect of the right upper arm. He had no other skin lesions.

Which one of the following is the most likely diagnosis?

1. Hypertrophic lichen planus
2. Stasis dermatitis
3. Lichen simplex chronicus
4. Contact dermatitis
5. Asteatotic eczema

Answer and discussion on next page

Answer: Stasis Dermatitis

Based on his history and the physical examination findings, the patient received a diagnosis of stasis dermatitis.

Presentation

Stasis dermatitis, also called venous eczema, is an inflammatory dermatosis that commonly occurs in patients with chronic venous insufficiency.¹ This condition typically presents as pruritic, erythematous papules and plaques that are scaly and consistently hyperpigmented due to melanin and hemosiderin deposition.² In addition to crusting and hair loss, lichenification may develop as a result of chronic scratching or rubbing as the condition progresses.

Stasis dermatitis most often affects the distal third of the lower limbs but may occur on the upper extremities, as in our patient’s case. In patients older than 65 years, the incidence of this condition is reported to be 6.2%.³ Risk factors include age, female sex, a family history of venous disease, a history of DVT, obesity, pregnancy, and prolonged standing.⁴ Patients with stasis dermatitis often present with concomitant varicosities, edema, secondary cellulitis, or ulceration.

Diagnosis

Stasis dermatitis is a clinical diagnosis; however, biopsy is warranted for patients with atypical features. Doppler ultrasonography may be considered to evaluate for the presence of chronic venous disease and/or DVT for patients with cutaneous manifestations alone, in the absence of clinical signs of venous insufficiency.

Among the conditions in the differential diagnosis are hypertrophic lichen planus, lichen simplex chronicus, contact dermatitis, and asteatotic eczema. Hypertrophic lichen planus is a chronic inflammatory disease that typically affects the anterior ankles and shins. Classic lesions present as planar, purple, polygonal, pruritic papules or plaques with scaling.⁶

Lichen simplex chronicus is localized skin thickening caused by repetitive scratching and rubbing. Patients present with well-demarcated, hyperpigmented, pruritic plaques with lichenification and scaling over the lateral ankle or posterior neck.

Contact dermatitis features well-demarcated erythema with vesicles, bullae, and superficial edema that presents within seconds to hours after exposure to an irritant. Chronic contact dermatitis presents as erythema, lichenification, hyperkeratosis, and scaling. Common irritants include soaps, detergents, industrial solvents, and fiberglass.

Asteatotic eczema is characterized by dry, pruritic, polygonally fissured skin with variable scaling of the lower legs and is seen primarily in elderly patients. Low-humidity environments, frequent bathing, and the use of harsh skin cleansers have been associated with this condition.⁶

Management

Treatment of stasis dermatitis includes daily emollient application and topical corticosteroids for severe inflammation. Continuous compressive therapy coupled with therapeutic lifestyle changes including exercise, weight loss, and limb elevation may also decrease the disease burden.⁷

The author discusses the case in this podcast:

Riley J. Burke, DO, is a captain in the US Air Force Medical Corps with the 22nd Special Tactics Squadron at Joint Base Lewis-McChord, Washington.

REFERENCES:

1. Weaver J, Billings SD. Initial presentation of stasis dermatitis mimicking solitary lesions: a previously unrecognized clinical scenario. J Am Acad Dermatol. 2009;61(6):1028-1032.
2. James WD, Berger TG, Elston DM. Cutaneous vascular diseases. In: James WD, Berger TG, Elston DM. Andrews’ Diseases of Skin: Clinical Dermatology. 12th ed. Philadelphia, PA: Elsevier; 2016:807-855.
3. Yalçın B, Tamer E, Toy GG, Öztaş P, Hayran M, Allı N. The prevalence of skin diseases in the elderly: analysis of 4099 geriatric patients. Int J Dermatol. 2006;45(6):672-676.
4. Bergan JJ, Schmid-Schönbein GW, Smith PDC, Nicolaides AN, Boisseau MR, Eklof B. Chronic venous disease. N Engl J Med. 2006;355(5):488-498.
5. Usatine RP, Tinitigan M. Diagnosis and treatment of lichen planus. Am Fam Physician. 2011;84(1):53-60.
6. Hirschmann JV, Raugi GJ. Lower limb cellulitis and its mimics: part II. Conditions that simulate lower limb cellulitis. J Am Acad Dermatol. 2012;67(2):177.e1-177.e9.
7. Burkhart CN, Adigun C, Burton CS. Cutaneous changes in peripheral venous and lymphatic insufficiency. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. Vol 2. 8th ed. New York, NY: McGraw-Hill:2110-2120.