Self-Care of Venous Stasis Dermatitis

Getting Your Legs Back

Declare your independence from Venous Stasis by learning to manage it yourself at home

By Grattan Woodson, M.D., FACP

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Table of Contents

Detailed Instructions for Home Care ........................................... 4 Daily Bathing Routine ............................................................. 7

Management of Simple Venous Stasis ........................................ 9 Chronic Venous Insufficiency ............................................... 11

Management of Complex Venous Stasis ................................... 12 With Dermatitis including Edema, Rash, or Ulcers .............. 12 The Natural History of Venous Stasis ................................... 13 Pathophysiology of Venous Stasis Ulcers ............................. 13 Ulcer and Wound Care .......................................................... 14 How to Put Jobst Stockings On ............................................. 15 Stocking Donners ................................................................... 16 Walking for Twenty Minutes Twice Daily ........................... 17 Signs and Symptoms of Wound and Ulcer Infection ............ 19

Jobst Stockings Options ............................................................. 19 General Information and Recommendations ............................. 21 Limitations of the Methods used in this Booklet ...................... 23

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GC Woodson MD PC 1418 Dresden Dr, Suite

225 Atlanta, Georgia 30319

404 574-2373 voice 404 298-5577 fax

www.DrGCWoodson.com

The Integral Institute for Women’s Health and Research, Inc. is pleased to provide support for this work. Chronic venous insufficiency affects postmenopausal women more than any other demographic. When poorly managed, the condition becomes progressively worse in some leading to disabling and painful leg ulcerations. The purpose of this booklet is to provide those with venous stasis the tools needed to effectively manage their condition at home on their own. Dr. Woodson’s goal for the patient with venous stasis is to achieve essential self-sufficiency in the management of the problem. Meredith PakPour Planning Director 3Apr2011 Copyright® 2011 Dedication: This pamphlet is dedicated to the good health and long life of Mrs. Hassanpour of Tehran, Iran.

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Detailed Instructions for Home Care To succeed in the early management of leg swelling due to venous stasis requires an abundance of patience and discipline because it’s a tough medical problem to get control of. It can be done by washing your legs before going to bed every night and putting on knee-high compression stockings upon awaking every morning before getting out of bed. That is what it takes nothing more or less.

The first step in healing your legs is deciding you are ready to make the sacrifices necessary to control venous stasis. The hardest thing about these tasks is to keep them up day in and day out without fail. This is what is required to stop the swelling, pain, and heal the legs. A consistent level of care is needed every day. Once healed, to keep your legs healthy requires you to continue these same practices. By the time venous stasis causes

swelling in the legs the underlying medical problem that leads to the disease, venous insufficiency has been developing for a long time. Chronic venous insufficiency CVI cannot be prevented. We think we know why some people develop it. For instance after suffering a blood clot in the leg. If we could we would have prevented that blood clot and in situations where the risk for that happening are high doctors do take precautions but VSI remains a very common condition seen regularly in the medical clinic by

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primary care practitioners. While surveys vary about 1% of the US population is affected by symptomatic VSI meaning swelling, pain, skin involvement, and ulcers. The prevalence of asymptomatic disease is probably many times higher than that.

The Clinical, Etiology, Anatomic, Pathophysiology

Classification of Chronic Venous Disease

Venous stasis is a chronic medical problem that slowly advances without effective management. The longer one waits to deal with this health challenge in an effective and permanent way the worse it becomes. Once chronic swelling develops surgery is indicated to redirect the errant blood flow that causes the disease and prevent its progression. Outpatient surgery performed under local anesthesia is a very effective treatment for symptomatic CVI and is covered by insurance plans and Medicare. I definitely recommend surgery to redirect the blood flow and prevent the terrible complications of the chronic progressive disease.

Venous stasis affects women especially those after menopause. This may be because women are more likely than men to become overweight after menopause and experience blood clots in the deep veins of their legs both of which are risk factors for venous insufficiency. Everyone with venous insufficiency has incompetent valves that don’t prevent blood from flowing back down the vein

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like they are suppose to do. The good news is conservative non-surgical treatment works for most of those who diligently apply it in the early stages of this disease preventing its complications.

that may work just as well but I have never had the need to try any other so I am unable to comment on their qualities. The correct stocking pressure for treatment of venous stasis varies according to the severity of the disease with the lowest pressure useful for early disease being 20-25 mmHg. Recommended Compression Stocking Pressure Based Upon

Clinical Severity of Chronic Venous Insufficiency

Pressure stockings work to keep the blood cells, proteins, enzymes and water within the vessels or lymphatics and out of the subcutaneous tissues of the skin where they cause swelling and tissue damage. It is these substances that really cause all the mayhem because they are loaded with bioactive products that

The treatment relies primarily upon the use of knee-high compression stockings worn from first thing in the morning until bedtime. I recommend the use of the Jobst brand hosiery in this booklet for the sole reason that they have always served my patients well. There are several competitive products available

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provoke a very intense immune response in the innocent tissues of the leg. This maelstrom damages the healthy tissue. These healthy tissues respond by release of more messages for help provoking additional response by the same innate immune system crew that ironically just leads to more destruction. It is a viscous cycle and all caused by one simple fact. The blood can travel down into the leg but can’t get out. The pressure in the veins rises too high causing everything that normally stays within the capillary bed to ooze out into the surrounding tissue. This includes water, fats, glucose, proteins, antibodies, red blood cells, white blood cells, and blood salts. The tissue becomes stuffed to the gills with all this and to top it off there is very little movement of normal oxygen into the tissue or waste products out. This condition is called ischemia in medicine and it hurts, as you know if you have VSI with swelling. All this goes on and on day in and day out whenever your legs are swollen and painful. Nature gave you a very tough body that can take a lot but unless you decide to take responsibility your own care because no one else can or will do this for you, then get prepared to suffer the consequences.

In people with VSI Jobst stockings are woven in a way to gently pump the fluid that leaves the capillary bed and enter the ankle tissues up the leg using the

lymphatic channels. The reclaimed fluid reenters the venous system at a higher-

level well above the legs. The energy driving the pump comes from walking.

Daily Bathing Routine Success in management of venous stasis relies in part on good hygiene. Using a sponge on a handle, a good quality Castile liquid soap, a shower chair, and a hand-held showerhead attachment for the shower or tub most people can manage this for themselves at

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home. The method is simple. After bathing sit on the shower chair and turn on the hand shower to wet the sponge and your legs.

Lula Handle Sponge including other

Head attachments

Shower/Bath Chair

Hand-Held Showerhead

Set

Liquid Castile Soap Spa Shampoo and Rinse Sprayer

Then squirt some liquid soap on you’re legs and then rub them gently using the sponge creating lather. The sponge being on a handle and with you sitting on the chair in the tub makes it possible to reach your feet and legs easily without any fear of falling. In one hand you control the sponge and in the other the hand-held showerhead. From time to time you may need to put the sponge down to squirt more soap on your legs. No hard scrubbing is

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required or desirable. Because all this takes place in the shower stall or tub the water goes safely down the drain. Management of Simple Venous Stasis With Edema but no Dermatitis, Skin, Rash or Ulcers

1) Take your bath or shower at night just before bed

2) Apply 12% ammonium lactate lotion on your legs 3) Upon arising apply 12% ammonium lactate lotion on your

legs

4) Before getting out of bed in the morning put your Jobst stockings on

5) Wear the Jobst Stocking all day and evening until you take

them off to bathe just before going to bed at night

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Severe Pitting Edema of the Left Leg

People with venous stasis have leg swelling because the valves of their veins fail to close. When upright the force created by the weight of the column of blood that has entered the venous system from below the level of the heart is transmitted down to the smallest venules in the leg.

When that pressure exceeds the capillary pressure of 25 mmHg in the leg, vascular fluid is pushed into the tissue space causing edema.

When firm finger pressure is applied to the shin, a pit is formed.

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Chronic Venous Insufficiency Secondary to Deep Vein Thrombosis Complicated by Venous Stasis Dermatitis

The right leg is chronically swollen due to a past medical history of deep vein thrombosis. The brownish discolored areas on the right leg are known as brawny edema and are due to the deposit of iron pigment (hemosiderin) in the subcutaneous tissues released from degenerated red blood cells that became trapped there. Cytokines in the form of interlukins and tumor necrosis factor (TNFα) are present in the leg having been released by activated lymphocytes. This occurs in response to prostaglandin E2 formed by

somatic cells. The somatic cells of the leg produce prostaglandins in response to undergoing chronic ischemic stress due to the low oxygen environment present most particularly along the lower anterior shin where the arterial supply is anatomically limited. The reddish tint of the skin and swelling of the foot and anterior shin’s subcutaneous tissues as well as the calf of the right leg are characteristic of inflammation. On physical exam legs like this blanch when touched, feel full or tight and warm and can be tender in response to light palpation. Patients report deep aching or burning pain is most common at night and in the late afternoon especially in the untreated. Treatment with diuretics is ineffective and contraindicated in venous stasis because the problem causing the edema is not related to intravascular volume overload and their use risks dehydration.

Venous Stasis

Dermatitis

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Management of Complex Venous Stasis With Dermatitis including Edema, Rash, or Ulcers

1) Take your bath or shower at night just before bed 2) Apply 12% ammonium lactate lotion

3) Upon arising in the morning put on 4) Before getting out of bed put on your Jobst the knee-high

Jobst Stockings 5) Wear the Jobst Stocking all day and evening until you take

them off to take your bath just before going to bed at night

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The Natural History of Venous Stasis

A composite graphical representation of the natural history from normal to severe complex disease of untreated venous stasis dermatitis due to venous insufficiency.

Pathophysiology of Venous Stasis Ulcers

Ulcers develop primarily in the lower third of the leg in people with venous insufficiency. The limited normal arterial supply to this region is one of the reasons. Cytokines are a contributing factor. These molecules are released by the immune system to remove dead and dying cells and to breakdown necrotic cells. Macrophages move across

the debris field scrubbing up necrotic remains. These tasks are necessary to make way for new growth. The problem in venous stasis is the disease progress continues because the causes and conditions underlying it remain active in the untreated person. The vascular fluids that enter the subcutaneous space from the capillary bed include blood cells that degenerate causing painful inflammation. The fluid also contains blood proteins, fats and enzymes that breakdown leading to further irritation. High venous pressure slows the flow of blood through the capillary bed causing chronic ischemia due to prolonged inadequacy of oxygen delivery to the somatic tissues. These are all potent contributors to ulceration in venous stasis. After the onset of venous stasis the skin will begin to accumulate a slight brownish discoloration. As time passes, there is more redness and then tenderness. Ultimately this phase is followed by rash then a cycle of ulceration followed by healing and ulceration anew. There can be considerable scarring and darkening of the skin in those who’ve had the condition for many years. It is of interest that clinical infections rarely contribute to the process making the routine use of oral or topical antibiotics unnecessary and in fact counter productive.

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Ulcer and Wound Care Skin rash and ulcers are treated with 12% ammonium lactate cream applied twice daily after bathing and in the morning before the dressings are applied. Weeping ulcers are lightly dressed after the bath with a non-adherent absorptive Teflon-like dressing material secured with paper tape to avoid skin injury. In the morning the old dressings are first removed then use a spray bottle filled with clean water to wash the ulcer and leg using an unscented baby wipe to clean the skin and remove the water. Next apply then 12% ammonium lactate lotion followed by the dressing placed on the open ulcer using the Teflon-like non-adherent absorptive material secured with paper tape. At last you are ready to don your stockings and begin the day. The shallow lesions will heal well as soon as the causes for their formation have been removed and the conditions for healing have been established. While fluid weeping from wounds and ulcers is much less after beginning simple compression therapy compared with before most healing lesions will continue to weep some until covered by new skin. To absorb the thin fluid, cover them with a dressing that does not stick to the newly forming tissue. I recommend use of a thin non-stick absorbent dressing placed between the site of discharge and the compression stocking to absorb the fluid draining from the skin, ulcer or wound. Use paper tape to hold the dressing in place. While venous stasis ulcers are rarely clinically infected, all will have some organisms growing there. 12% ammonium lactate has several interesting healing properties. First it removes dead cells from the ulcer bed. Second it has antibacterial and antifungal properties without being an antibiotic. Third it helps dry skin and prevents itching. There are new prescription therapies for chronic skin ulcers that use growth factors that can be added to the above regime that should work very well. Discuss this with your doctor. The

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important thing to keep in mind however is the reason the ulcers are there in the first place is the build up of all that fluid in the tissues of the leg. If you can get that fluid to go away using the Jobst stockings then the ulcer is going to heal. The only way to cure the problem though is to have the venous surgery to redirect the blood flow so that the problem goes away. Research shows ulcers in people like you heal up most of the time and don’t come back. Even with the surgery though, you still need to use the stockings but at least you don’t have to deal with those awful ulcers anymore and your legs don’t hurt nearly as much. You can walk better too.

How to Put Jobst Stockings On It is hard to put a properly sized 20-25 mmHg compression stockings on if your feet and legs are swollen. This is why I recommend putting the stockings on the first thing in the morning before getting out of bed because as soon as you stand up and begin moving around the swelling begins anew. In the short time it takes to bathe in the morning enough fluid can accumulate in the feet and legs of those with venous insufficiency that the stockings can become too difficult to put on comfortably.

Our goal is for no fluid to ever again flood into the tissues and cause them to swell. This is the condition for the skin disease to break out and if we prevent the swelling from occurring there is no cause for any skin problems to erupt. This is why the ideal time to put the stockings on is when there is the least amount of fluid in the skin of the legs and that time is known to be the first

thing in the morning after lying in bed all night. Since daily washing of the feet and legs is a requirement for successful care of venous stasis, the only logical time to work a bath into the daily

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routine is just before bedtime. This is why we suggest you bathe at night instead of the morning.

To don compression hose begin by rolling the stockings up the night before and placing them on your bedside table along with a pair of latex gloves. When ready to get started the next morning, put on the gloves and pick up one of the rolled up stockings and place on your foot being careful to line up the seams correctly.

Grasp both sides of the stocking tightly as you roll and pull the tightly woven elastic stocking down the foot, over the heel up and over the ankle in the usual way. Make sure to keep the stocking toe and heel seams lined up straight as you go. When you are well over the heel and clearly above the ankle, give the stocking a proper stretch and complete the job.

Stocking Donners If you are unsuccessful with the above method of putting on the compression stockings there are two other good options to consider. One is the Easy Roll Stocking Donner, which allows you to place the stocking on a plastic ring that the manufacturer claims makes it easy to roll it over your foot and up leg. This device costs about $40.

Easy Roll Stocking Donner

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The second is the Jobst Stocking Donner. According to Jobst, it is “Designed to aid in the application of Jobst Vascular Stockings. Place stocking on the center frame. Grasp the foam handles and step down into the stocking. Ideal for patients with arthritis and limited bending motion.” This device costs about $40.

Walking for Twenty Minutes Twice Daily Walking while wearing compression stockings promotes the pumping action inherent in the woven design of the Jobst hosiery. This encourages the movement of excess tissue fluid out of the subcutaneous tissues of the lower leg and into the lymphatic channels that pass upward through the retroperitoneum anterior of the spine gaining access to the superior vena cava via the thoracic duct. I recommend walking for 20 minutes twice daily. This will help you heal faster and fell much better. Walking is the way that nutrition and oxygen is brought to the cartilage that lines the joints of the leg and is responsible for the removal of waste products from the joints and the leg. These benefits of walking reduce symptoms of osteoarthritis including pain, swelling, and redness as well as improving mobility. In addition because the inflammatory chemicals released by venous stasis dermatitis gain access to the

Jobst Stocking Donner

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blood circulation they worsen osteoarthritis elsewhere in body both near and far from the legs. Once effective control of venous insufficiency has been established by a method like the one in this booklet, the source of these pain-causing chemicals are cut off. As a consequence, some people have less pain and stiffness in the body as a whole. Regular walking promotes the health of the muscles, tendons, ligaments and joints of the entire lower extremity. The physical stress and strain of this activity provide the crucial instructions where and how much tissue needs to be rehabilitated. Walking is the precise natural means of transmitting this required instruction set to all the tissues of the leg damaged by venous stasis by providing it with the demand-based growth-path road map. In response, the leg tissue cells increase their numbers more rapidly, live longer, and work harder to return the leg and skin to normal health. Nutrition is Critical for Tissue Repair Those with significant soft tissue damage due to venous stasis dermatitis require a high protein diet during the recovery phase of this disorder. Protein is used to rebuild the tissues injured by the disease. Nutrition is fundamental for tissue repair. The new cells are composed primarily of amino acids that come from your diet. Fresh food is the best food. An excellent source of amino acids is high quality animal protein derived from eggs, fish, chicken, beef, pork, goat, or lamb. Fresh fruits and vegetables are important for

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maintaining good bowel function, taste great and add to the quality of the culinary experience tremendously. Vegetarians can obtain all 8 essential amino acids from a diet composed of whole grains and legumes especially when supplemented by nuts and seeds too. Vegetarians do need to obtain iron and B12 from a supplement because these nutrients are lacking in a purely vegan diet. Adding a vegan multiple vitamins to your daily regimen that includes these nutrients is a good way to fill the gap. Vitamin D is required for healing, building strong bone, muscle strength, reduces risk of falling and increasing immune function. I recommend taking 2,000 IU of vitamin D3 as oil filled capsule taken in the morning each day. This is a safe dose and is in addition to the vitamin D you will also be getting in your calcium tablets, multiple vitamin, food sources and from the sun.

Signs and Symptoms of Wound and Ulcer Infection A thin slightly yellow fluid is what to expect from a non-infected wound. A thick, colored and/or foul smelling heavy discharge is what characterizes an infected wound or ulcer. The infected lesion bleed more often than non-infected ones and the skin surrounding infected wounds or ulcers are often swollen, tinted red and more tender than usual. Infected skin, wounds, or ulcers require evaluation and management by a medical professional. Jobst Stockings Options For management of venous stasis I recommend purchase of 5 pair of ready-made knee-high Jobst compression stockings in a pressure of 20-25 mm Hg. Having 5 pair allows you to rotate them on a regular basis, which prolongs their service life. Jobst knee-highs come in three styles of interest to those with venous stasis, in a

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variety of colors with each available in an open or closed toe. The basic styles include Ultra Sheer and Opaque, two elegant designs exclusively for women and a style that is popular with both genders called For Men. These stockings cost around $35 a pair online.

Standard Jobst Thigh-High Compression Hose

Styles and Colors

A Partial List of Jobst Compression

Stockings Color Options

Jobst For Men

Knee-High Jobst Opaque

Knee-High Jobst Ultra Knee-High

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Washing Instructions for Jobst Stockings Jobst Stockings and can be laundered in a washing machine or by hand in the sink. If in the machine place them in a mesh laundry bag and wash them with a load that can use a mild detergent and doesn’t require bleach or a laundry softener since these can damage the stockings. To hand wash your compression hose I recommend an odorless environmentally friendly dishwashing soap like Seventh Generation in the sink with hot water then rising with cold water. The tightly woven construction of the nylon fabric stockings break when wrung dry so the preferred way to dry your hose is to pat them between two towels and then hang them up. They are usually dry by morning. In my opinion hand washing is superior to machine washing. General Information and Recommendations

1) I recommend using an unscented liquid soap. Castile soap is my choice and is widely available. Amazon.com has a good selection of options to choose from with various features and price points. Consider purchasing a gallon of the soap. You will also need to pick up a few small 6 oz plastic squeeze bottle from the drug store and transfer the Castile soap into the smaller bottler for use in the bath.

2) 20-25 mm Hg medium pressure Knee-High Jobst Stockings are widely available online and locally from medical supply stores. I recommend buying on Amazon.com again because there you have access to the entire selection of Jobst options, the best prices and if you are a Prime member free shipping. If cared for as described in this text these stockings can be expected to last about a year especially considering that you are going to be rotating them. They do wear out eventually.

3) Medical grade powder free latex gloves: Wearing medical grade latex gloves that fit your hand properly greatly

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enhances your grip. People with latex allergy can use nitrile gloves as an effective alternative. This makes it easier to control the stocking as you guide it up the foot and leg. When used with care, good quality gloves can be reused several times. You buy them in boxes of 100 from a local medical supply store or online for around $9.00 in size small, medium, or large.

4) 12% ammonium lactate lotion is available in various sizes by different vendors offered on Amazon.com. Again the selection and price points available on Amazon cannot be beat by any other retailer. There are probably differences in the emollient qualities of the different offerings. The most important element in the product is the ammonium lactate and all have that virtue. You can always add your own preferred cream. For instance if you have very dry skin and favor a water in oil cream like Nivea or Eucerin, simply apply it after the ammonium lactate, which is an oil in water lotion.

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Limitations of the Methods used in this Booklet This pamphlet addresses leg swelling due to venous stasis caused by venous insufficiency exclusively. It is advisable to have a solid medical diagnosis of venous stasis from a competent medical professional before beginning compression therapy. There are other causes of leg swelling that might superficially resemble the images and descriptions in this pamphlet that are due to entirely different medical conditions. For instance skin ulcers and leg swelling are seen in some people with peripheral vascular disease, diabetes, immunological disorders and other chronic skin disorders. These patients require competent medical management and should not use the methods suggested in this pamphlet for treatment, as it can be harmful to their health.