Author: Millicent Osti, Resident Medical Officer, The Royal Melbourne Hospital, Melbourne, VIC, Australia; Rosemary Nixon, Dermatologist, Melbourne, VIC, Australia. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. October 2018.
Lipodermatosclerosis is a chronic inflammatory condition characterised by subcutaneous fibrosis and hardening of the skin on the lower legs.
Lipodermatosclerosis is also known as sclerosing panniculitis and hypodermitis sclerodermaformis.
Lipodermatosclerosis is common, affecting middle aged or older people. It is more common in women and is associated with immobility and a high body mass index (obesity) .
Lipodermatosclerosis is an inflammatory skin condition resulting from underlying venous insufficiency. This is caused by:
The resulting venous hypertension causes in an increase of leukocytes within the veins, which then migrate into surrounding tissue. The leukocytes become activated, attracting and releasing proinflammatory cells and cytokines inducing a chronic inflammatory state. Increased collagen production leads to the fibrosis of subcutaneous fat .
Acute lipodermatosclerosis may mimic cellulitis, with lower limb induration, erythema, pain, itch, aching, and a feeling of swelling or heaviness of one or, more often, both lower limbs .
In the acute phase, signs may be localised to a single plaque but are usually more widespread. The most commonly affected areas are the pretibial or medial aspect of the leg.
Induration, erythema and pain continue in the chronic phase of lipodermatosclerosis. Subcutaneous fibrosis may result in significant narrowing of the distal lower limb, causing the leg to have an ‘upside-down champagne bottle’ appearance [1,2].
Other clinical features of chronic venous insufficiency may be present including hyperpigmentation of the skin from haemosiderin deposition, atrophie blanche, varicosities, venous eczema, and venous ulcers.
Lipodermatosclerosis is associated with poor wound healing because of the chronic inflammatory state and fibrosis. Venous ulcers commonly co-exist and may be difficult to treat.
Lipodermatosclerosis is usually diagnosed clinically. Underlying venous insufficiency may be confirmed using doppler studies.
Biopsy is helpful but should be performed with caution because of the likelihood of poor wound healing . It also needs to include the panniculus. Characteristic biopsy features are dependent on the stage of disease but include subcutaneous lobular and septal changes including:
Differential diagnoses for lipodermatosclerosis can include:
Physical activity (walking) should be encouraged to increase the functionality of the calf muscle pump. Weight reduction is effective if obesity is a factor.
Mechanical compression therapy using compression stockings or socks is the mainstay of treatment, encouraging venous return and assisting with symptom control, however may be poorly tolerated in some individuals.
Elevation of the legs can help reduce oedema and pain.
Treatment of underlying venous insufficiency can improve symptoms and may reduce the risk of ulcer recurrence. Referral to a vascular surgeon should be considered. Leg vein therapies include:
Venous insufficiency is a progressive disease. Although treatment can improve symptoms or slow progression, associated conditions such as lipodermatosclerosis are usually chronic and recurring.
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