Lipodermatosclerosis · What Is It, Causes, Symptoms, and More

The exact cause and pathogenesis of lipodermatosclerosis is unknown, however, it is closely associated with venous disease, including chronic venous insufficiency. Damage of the valves within the veins results in poor blood flow back to the heart and increased pressure in the veins, known as venous hypertension. The increased pressure facilitates the diffusion of fibrinogen, an inflammatory mediator, into the dermis, where it transforms into fibrin. Fibrin then forms a cuff around the capillaries, leading to hypoxia in the surrounding area. Additionally, increased venous pressure and inflammation of the vein wall cause increased production of matrix metalloproteinases (i.e., enzymes that break down protein) which can degrade collagen, contributing to the formation of venous ulcers. These physiologic changes can lead to changes in the skin's appearance, making it look indurated or hardened, thickened, and discolored. 

A history of deep vein thrombosis (DVT) can increase the risk of developing lipodermatosclerosis as it can result in damaged valves in the veins and lead to venous insufficiency. Obesity can also increase the risk of lipodermatosclerosis due to added pressure on the veins. Lifestyle choices (e.g., occupations that involve prolonged standing, sedentary lifestyle), advanced age, tobacco smoking, and hypercoagulable states (e.g., protein C or S deficiency) are additional risk factors.  

The signs and symptoms of lipodermatosclerosis can differ depending on whether the condition is in the acute, subacute, or chronic stage. If the symptoms are present for less than one month, it is considered acute lipodermatosclerosis and can present with tender, painful, erythematous, and localized plaques (i.e., skin lesions >1 centimeter [cm]). In up to half of cases, both legs are involved.  

Subacute lipodermatosclerosis, present for one month to one year, presents as nontender, hyperpigmented, sclerotic plaques. The hyperpigmentation is due to hemosiderin deposition, which is a protein that helps the body store iron. When it leaks out of damaged capillaries, this can result in a reddish-brown appearance of the skin. Often at this stage, non-healing venous ulcers can form on the legs above the ankle. The presence of varicose veins (i.e., visible, enlarged veins) is also common in acute to subacute lipodermatosclerosis.   

Chronic lipodermatosclerosis, which occurs when the skin condition is present for more than one year, results in the leg taking on a tapered appearance, often referred to as an ‘inverted champagne bottle’. The proximal leg is swollen and edematous whereas the lower leg closer to the ankle is slimmer, atrophied, and scarred from fat necrosis and chronic ulceration.  

Treatment of lipodermatosclerosis aims to prevent the progression of disease, improve blood flow, and reduce symptom severity. Typically, treatment starts with compression therapy, including the use of compression stockings or bandages to the affected areas to improve venous circulation. The individual may try to elevate their legs above their hearts as frequently as possible to reduce swelling and exercise regularly to increase blood flow throughout the body. Non-pharmacologic options such as emollients and moisturizers can help keep the skin hydrated and help prevent leg ulcers.  

Topical medications such as corticosteroid cream (e.g., clobetasol propionate) can be used for anti-inflammatory purposes, and topical capsaicin cream can be used for pain relief. Intralesional (i.e., injections) triamcinolone acetonide can be used as treatment, however, it should be noted that it can cause skin lightening (i.e., hypopigmentation) in darker skin colors and skin atrophy with long-term use. Other medications including synthetic anabolic steroids (e.g., stanozolol, danazol, oxandrolone) help promote fibrinolysis, whereas pentoxifylline (i.e., an anti-fibrinolytic and vasodilator) and hydroxychloroquine can be used to improve edema and erythema.  

Ultrasound therapy, a noninvasive treatment where sound waves are used to penetrate the tissue and improve blood circulation, has been shown to reduce the induration and erythema of the legs and alleviate symptoms. In severe cases of lipodermatosclerosis, surgical intervention performed by a vascular surgeon or interventional radiologist may be necessary. Procedures such as vein stripping (i.e., the removal of a damaged vein) or valve repair might be required.