In the United States, 6%-7% of the population aged older than 50 years has some form of chronic venous insufficiency. The incidence peaks in women aged 40-50 years and men aged 70-79 years. Risk factors include age, smoking, family history, preexisting varicose veins, previous trauma to the venous system (eg, vein stripping, nonsurgical trauma), hypercoagulable states (eg, protein C or S deficiency), history of deep vein thrombosis, obesity, and lifestyle choices (eg, standing occupations, sedentary lifestyle). Clinical features of chronic venous stasis include varicose veins, lower extremity edema, chronic aching pain from venous hypertension of muscle and fascial compartments, and, finally, progression to lipodermatosclerosis and the development of nonhealing ulcers.
The exact pathogenesis of lipodermatosclerosis is unknown. It is believed that venous disease (ie, venous hypertension, venous incompetence, etc) allows diffusion of capillary contents such as fibrinogen and other inflammatory mediators into the dermis. Fibrinogen is polymerized to fibrin, which forms a fibrin cuff around capillaries, leading to a relative hypoxic state. This is complicated by elevated proteolytic activity involving matrix metalloproteinases and fibrinolytic mediators from the plasminogen activating pathway, which degrades the collagen matrix, resulting in venous ulcers.
I83.10 – Varicose veins of unspecified lower extremity with inflammation
410016009 – Lipodermatosclerosis
- Cellulitis – Look for infectious symptomatology, lymphocyte counts.
- Erythema nodosum – Septal panniculitis, minimal venous stasis, ischemic / membranocystic fat necrosis, and prominent granulomatous infiltrate with Langhans giant cell formation.
- Fat necrosis – Look for history of trauma or pancreatitis.
- Granuloma annulare – Look for annular lesions, diagnostic on skin biopsy.
- Lupus panniculitis (lupus profundus) – Usually affects the face; end-stage lipodystrophy from effects of chronic inflammation and fibrosis of subcutaneous fat.
- Sarcoidosis – Can be either an isolated cutaneous form or a multisystem granulomatous response (which should be ruled out by further investigations).
- Erythema induratum
- Morphea – Initial stages present as ivory-colored, indurated plaques with a peripheral violaceous (lilac) ring.
- Necrobiosis lipoidica – Presents as asymptomatic, yellow / orange-red, indurated, mildly atrophic patches or plaques with prominent vessels that may later ulcerate.
- Nephrogenic systemic fibrosis – Usually with history of gadolinium exposure during MRIs in the context of impaired renal function.
- Pretibial myxedema – Check for thyroid disease.
- Scleromyxedema – A rare disorder from mucin deposition (identifiable on biopsy) in skin and other internal organs.
- Traumatic panniculitis – Look for history of trauma.