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Chapter 39: Skin Diseases of the Legs

Brittney Schultz; Noah Goldfarb

INTRODUCTION

The legs are predisposed to dermatoses that are gravity-dependent, including stasis dermatitis and vascular conditions such as leukocytoclastic vasculitis, the pigmented purpuric dermatoses, and livedo reticularis. Legs are also the site of frequent trauma and thus are susceptible to conditions that may be induced by trauma including superficial thrombophlebitis, pyoderma gangrenosum, necrobiosis lipoidica, chronic ulcers, and cellulitis. In patients with pre-existing vascular conditions affecting the lower extremities, including diabetes mellitus, venous insufficiency, and peripheral vascular disease, traumatic wounds may take longer to heal with an increased risk of infection.

APPROACH TO DIAGNOSIS

Skin diseases involving the arms can be broadly placed into the following categories starting with the most common diseases (Table 39-1):

  • Inflammatory Dermatoses

  • Infectious Diseases

  • Neoplasia

  • Systemic Diseases

  • Vascular Diseases

Table 39-1.Differential diagnosis for skin diseases of the legs.
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Table 39-1. Differential diagnosis for skin diseases of the legs.
Disease Epidemiology, History, and Physical Examination
Inflammatory Dermatoses

Asteatotic dermatitis (eczema craquelé, xerotic dermatitis)

image

Epidemiology:

 Common.

 M > F

 Age: Typically > 60 years.

History:

 Pruritus and dry skin.

 Waxing and waning course.

 Worse in winter and low humidity climates. May be exacerbated by excessive bathing in absence of moisturization and use of harsh soaps.

Physical Exam:

 Poorly-demarcated, erythematous or hyperpigmented, fissued/cracked, mildly scaly plaques on bilateral anterior lower legs. May have a shiny/glazed appearance.

 Distinguishing feature: cracked, "dry riverbed" appearance.

 (see Chapter 8 Dermatitis)

Stasis dermatitis

image

Epidemiology:

 Common.

 F > M.

 Age: Middle-aged and elderly adults.

History:

 Asymptomatic or pruritic.

 Associated with leg swelling.

 May have history of varicose veins and thrombophlebitis.

Physical Exam:

 Erythematous, scaly plaques on bilateral anterior lower legs, especially medial ankles.

 Plaques may also be hyperpigmented, lichenified, or sclerotic.

 Distinguish from cellulitis by bilateral distribution and lack of systemic symptoms.

 (see Chapter 28).

Nummular eczema

image

Epidemiology:

 Common.

 M > F.

 Age: Bimodal; peaks in young and older adults.

History:

 Pruritus is common.

 Chronic, waxing and waning course.

 Worse in fall and winter.

Physical Exam:

 Round, light pink, scaly, thin, 1–3 cm plaques, most commonly located on the extremities, especially on the legs, but can occur anywhere on the body. Sometimes they can be more moist and indurated and sometimes more xerotic with reticular fissuring. Can have overlying crusting and impetiginization.

 Distinguish from psoriasis by fine scale, reticular fissuring, less well-demarcated borders, and lack of involvement of classic psoriasis areas (scalp, ears, elbows, knees, gluteal cleft, umbilicus).

 (see Chapter 8).

Psoriasis vulgaris (chronic plaque psoriasis)

image

Epidemiology:

 Common.

 M = F.

 Age: Any age but bimodal distribution peaks in 20s and 50s.

History:

 Asymptomatic to mildly pruritic. Chronic course.

 Associated with inflammatory arthritis and cardiovascular comorbidities (e.g., obesity, diabetes mellitus type II, hyperlipidemia, hypertension, as well as atherosclerotic cardiovascular and cerebrovascular disease).

 Family history of psoriasis.

Physical Exam:

 Well-demarcated, salmon pink to red papules and plaques with overlying white/silvery, thick, adherent scale. Most ...

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