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Lipodermatosclerosis - Skin
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Lipodermatosclerosis - Skin

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Contributors: Patricia Ting MD, Ben Barankin MD, Jeffrey D. Bernhard MD, Belinda Tan MD, PhD, Noah Craft MD, PhD, Lindy P. Fox MD, Lowell A. Goldsmith MD, MPH, Michael D. Tharp MD
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Synopsis

Lipodermatosclerosis, also known as lipomembranous panniculitis, sclerosing panniculitis, venous liposclerosis, and hypodermitis sclerodermiformis, is an inflammation of subcutaneous fat, usually on the lower extremities secondary to chronic venous insufficiency. It can be classified into acute, subacute, and chronic stages. Acute lipodermatosclerosis appears as a localized, exquisitely tender erythematous indurated plaque (ie, <1 month), while subacute (1 month to 1 year) and chronic lipodermatosclerosis (>1 year) appear as a nontender, hyperpigmented, sclerotic plaque, which can contain venous ulcers. Advanced lipodermatosclerosis on the lower leg has the appearance of an "inverted champagne bottle" whereby the proximal leg is edematous from chronic venous stasis while the lower portion of the leg is atrophied and sclerotic from fat necrosis (or lipodystrophy) and scarred from chronic ulcerations.

In the US, 6 to 7% of the population (over age 50) has some form of chronic venous insufficiency. The incidence peaks in women at age 40-50 and men at age 70-79. Risk factors include age, smoking, family history, pre-existing varicose veins, previous trauma to the venous system (eg, vein stripping, non-surgical trauma, etc), history of deep vein thrombosis, obesity, and lifestyle choices (eg, standing occupations, sedentary lifestyle, etc). 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.

Codes

ICD10CM:
M79.3 – Panniculitis, unspecified

SNOMEDCT:
410016009 – Lipodermatosclerosis

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • 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.
  • Morphea – initial stages present as ivory-colored indurated plaques with 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.
  • Sarcoidosis – can be either an isolated cutaneous form or multisystem granulomatous response (which should be ruled out by further investigations).
  • Scleromyxedema – a rare disorder from mucin deposition (identifiable on biopsy) in skin and other internal organs.
  • Traumatic panniculitis – look for history of trauma.

Best Tests

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Management Pearls

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Therapy

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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References

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Last Updated: 11/01/2013
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Lipodermatosclerosis - Skin
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Lipodermatosclerosis : Lower leg, Hardened skin, Hyperpigmented plaques, Erythematous plaques
Clinical image of Lipodermatosclerosis
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