GPAtlas🧭 When to suspect
Suspect venous eczema (also called gravitational, varicose or stasis eczema) in a patient with:
• Skin over the lower legs that is itchy, red, scaly or weepy
• Those changes 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 and tender
• Develops reddish-brown discolouration from haemosiderin
As fibrosis progresses it constricts the lower leg below 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.
First, 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 or lipodermatosclerosis | Cellulitis |
|---|---|---|
| Laterality | Often bilateral | Almost always unilateral |
| Onset | Chronic, fluctuating | Acute, rapidly spreading |
| Dominant symptom | Itch | Pain and tenderness |
| Systemic upset | Absent | Fever and malaise common |
| Venous signs | Present (staining, varicosities, oedema) | Usually absent |
Source: NICE CG168 · DermNet
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