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Lipodermatosclerosis
Evidence Levels: A Double-blind study B Clinical trial ≥ 20 subjects C Clinical trial < 20 subjects D Series ≥ 5 subjects E Anecdotal case reports
Lipodermatosclerosis (LDS) refers to the ‘woody’ indurated skin of the lower extremities in patients with longstanding venous disease. LDS is a form of fibrosing panniculitis that results from chronic inflammation and progressive fibrotic process of the skin and subcutaneous tissue secondary to chronic venous insufficiency. The diagnosis is based on clinical findings. LDS more often affects middle-aged to elderly, obese women with venous abnormalities. It is usually located above the medial malleolus on the lower leg. Venous ulcers may develop within LDS. Pain is the most consistent presenting symptom. There is a clinical continuum of LDS ranging from acute to chronic disease. The acute form presents with painful, tender, and slightly indurated plaques. Lesions are usually well-demarcated from normal skin. Acute LDS can be confused with cellulitis, thrombophlebitis, erythema nodosum, or inflammatory morphea. The chronic variant, which is strongly associated with venous insufficiency, is densely indurated with pronounced hyperpigmentation, and less painful than the acute form. In its late stages, chronic LDS alters the shape of the leg, making it look like an ‘inverted champagne bottle.’ Bilateral involvement can be seen in up to 50% of cases. Extreme fibrosis may lead to limitation in muscle pump function and ankle join mobility, which may worsen the condition.
Management Strategy
The current treatment of choice is the combination of stanozolol and compression therapy . However, patients with acute LDS often find compression therapy painful. In this case stanozolol is used alone. Stanozolol, a synthetic anabolic steroid, is contraindicated in patients with uncontrolled hypertension and heart failure. Of note, although stanozolol is no longer commercially available in the United States, danazol has been used as an alternative. However, stanozolol is still available in Europe, and its purchase is unregulated online. Pentoxifylline is an alternative that stimulates fibrinolysis but may cause gastrointestinal upset. Niacin has some fibrinolytic properties and has also been used. Other treatments, such as antibiotics, antiinflammatory agents, antimetabolites, and long-term cimetidine , have also been proposed. Intralesional triamcinolone, platelet-rich plasma, and topical capsaicin may be helpful. Surgical approaches include subfascial perforator endoscopic surgery (SEPS), perforator vein sclerotherapy, ultrasound therapy, and complete excision of LDS followed by split-thickness skin graft repair . Other simple lifestyle measures include weight loss, increased leg elevation, and increased exercise to improve calf muscle pump function.
Specific Investigations
The clinical spectrum of lipodermatosclerosis
Kirsner RS, Pardes JB, Eaglstein WH, et al. J Am Acad Dermatol 1993; 28: 623–7.
The diagnosis of LDS is based on clinical findings. In most cases, biopsy is not advised because 50% of biopsy sites do not heal.
Acute lipodermatosclerosis is associated with venous insufficiency
Greenberg A, Hasan A, Montalvo BM, et al. J Am Acad Dermatol 1996: 35: 566–8.
One-third to one-fifth of patients with acute LDS lack evidence of venous disease with routine venous evaluation. Chronic LDS may present after, or independently of, acute LDS.
Lipodermatosclerosis: the histologic spectrum with clinical correlation to the acute and chronic forms
Hurwitz D, Kirsner RS, Falanga V, et al. J Clin Pathol 1996; 23: 78.
Biopsy specimens of acute LDS showed little epidermal change or capillary proliferation. In the subcutis, there was lobular and septal panniculitis with eosinophils, fibrin thrombi, and purpura. Biopsies of chronic LDS showed dermal changes associated with venous insufficiency, including capillary proliferation, hemosiderin deposition, and fibrosis. Epidermal hypertrophy was also found.
Lipodermatosclerosis: a clinicopathological study of 25 cases
Walsh SN, Santa Cruz DJ. J Am Acad Dermatol 2010; 62: 1005–12.
Biopsies may distinguish LDS from other fibrosing entities. Most cases show pseudoxanthoma elasticum–like elastic fiber calcification within the septae.
Skin iron deposition characterises lipodermatosclerosis and leg ulcer
Caggiati A, Rosi C, Casini A, et al. Eur J Vasc Endovasc Surg 2010; 40: 777–82.
Lipodermatosclerosis is always accompanied by hemosiderin deposition.
Duplex venous imaging: role for a comprehensive lower extremity examination
Badgett DK, Comerota MC, Khan MN, et al. Ann Vasc Surg 2000; 14: 73–6.
Results of duplex scanning of 205 lower extremities with varices: 106 not previously operated and 99 previously operated for varicose veins
Egeblad K, Baekgaard N. Ugeskr Laeger 2003; 3016–8.
Color duplex ultrasound can accurately detect the specific location of lower extremity venous insufficiency that often leads to LDS.
Quantifying fibrosis in venous disease: mechanical properties of lipodermatosclerosis and healthy tissue
Geyer MJ, Brienza DM, Chib V, et al. Adv Skin Wound Care 2004; 17: 131–42.
Ultrasound indentometry was used to quantify fibrotic tissue in LDS.
Excision of lipodermatosclerotic tissue: an effective treatment for non-healing venous ulcer
Ahnlide I, Bjellerup M, Akesson H. Acta Derm Venereol 2000; 80: 28–30.
In seven cases, laser Doppler scanning showed an increase in blood flow in lipodermatosclerotic skin, which decreased after surgical removal of the affected area.
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