GPAtlas🧭 When to suspect
Suspect venous eczema (also called gravitational, varicose or stasis eczema) in a patient with itchy, red, scaly or weepy skin over the lower legs, set against a background of chronic venous insufficiency – varicose veins, ankle swelling, or brown staining of the skin. It usually affects the gaiter area of one or, more often, both lower legs.
Suspect lipodermatosclerosis when the lower-leg skin becomes woody and indurated, tender, and develops reddish-brown discolouration from haemosiderin. As fibrosis progresses it constricts the lower leg above a swollen calf, producing the characteristic "inverted champagne bottle" shape. Both conditions sit on the same spectrum of venous skin change (CEAP class C4) and are diagnosed clinically.
The single most useful clinical move is to recognise this as venous, not infective. Bilateral, itchy, chronically discoloured legs are far more likely to be venous eczema than cellulitis, and the reflex to reach for antibiotics is the commonest error in the "red leg".
| Feature | Venous eczema / lipodermatosclerosis | Cellulitis |
|---|---|---|
| Laterality | Often bilateral | Almost always unilateral |
| Onset | Chronic, fluctuating | Acute, rapidly spreading |
| Dominant symptom | Itch | Pain and tenderness |
| Systemic upset | Absent | Fever / malaise common |
| Venous signs | Present (staining, varicosities, oedema) | Usually absent |
Source: NICE CG168 · DermNet
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