Dermoscopic findings in chronic venous insufficiency

Abstract

Background

Chronic venous insufficiency (CVI) causes cutaneous changes. This prospective observational study reveals dermoscopic findings in CVI.

Methods

Successive CVI patients of ≥18 years were included in the study. American Venous Forum classification for CVI was utilized. All underwent clinical examination, duplex ultrasound, and dermoscopy. Pregnancy, pedal edema, or pigmentation from causes other than CVI, active/healed venous ulcers, prior venous interventions, arterial insufficiency, and deep vein thrombosis were excluded.

Results

Eighty patients were studied. Fifty-six were males [mean age of 58.9 years (SD-12.09)], and twenty-four were females [mean age of 53.9 years (SD-12.8)]. Sixty-two had bilateral, and eighteen had one limb involvement (total 142 limbs). Pigmentation was observed in 120 limbs, varicose veins in 138 limbs, eczema in 45, and edema in 33 limbs. On dermoscopy, the pigment network was accentuated and diffuse in 105 limbs and accentuated but patchy in 16 limbs. Vessel morphology noted were dotted vessels in 67 limbs, linear curved vessels in 45 limbs, linear curved vessels with branches in 11 limbs, and linear vessels in 7 limbs. Scales were white and diffuse in 56 limbs and white but patchy in 8 limbs. White and brown focal structureless areas were seen in 20 and 18 limbs, respectively. Blue-grey linear cords were seen in 34 and blue-grey clods in 6 limbs.

Conclusion

CVI causes changes in vessel morphology, pigmentary, and scaling patterns in the skin which are picked up by dermoscopy. Further longitudinal studies could provide insight into the temporal progression of CVI.

Introduction

Chronic venous insufficiency (CVI) is highly prevalent.¹ It adversely affects the quality of life,² and its treatment is prolonged and expensive.^2,3 There are lacunae in our knowledge with respect to CVI. The hemodynamics of the venous system is not well understood.4, 5, 6 Anatomical details and hemodynamic assessments do not fully explain the severity of manifestations of CVI.⁷ Moreover, symptomatic relief following treatment is also partial.^3,6

Alterations in skin microcirculation^7,8 and capillary morphology⁷ have been reported in CVI. Capillaroscopy and laser flowmetry are used to assess skin microcirculation. Experience tells us that the cost, availability, and expertise limit the use of capillaroscopy and laser flowmetry in day-to-day practice. There is a need of a bedside or office-based tool to identify patients who are prone to developing skin changes and ulcers.⁹

Dermoscopy is increasingly being used to differentiate various pigmentary and inflammatory disorders of skin.¹⁰ Hence, it is intuitive and logical to explore its usefulness in patients with CVI. Presented in this pilot study is the initial experience of dermoscopy in CVI patients.

Materials and methods

This was a prospective, observational, and open-label study conducted at a tertiary care hospital from November 2018 to March 2020. Institutional Ethics Committee clearance was obtained before the commencement of the study. A written informed consent was taken from all patients.

Inclusion criteria

All patients above 18 years of age with CVI were included in the study. Definition and classification of venous insufficiency given by the American Venous Forum were used for the study.¹¹ This system uses clinical findings on examination along with duplex ultrasound (DU) findings to categorize the patients.

Exclusion criteria

Patients who were unwilling to participate and those with pedal edema due to causes other than CVI and pregnancy were excluded. Those with active venous ulcers, prior venous interventions, systemic diseases with dermatological manifestations, arterial insufficiency, and recent or old deep vein thrombosis of lower limbs were also excluded.

All patients were examined by vascular surgeon and dermatologist. Clinical findings like spider and reticular veins, varicose veins, hyperpigmentation, eczematous changes, pedal edema, and signs of inflammation (erythema, warmth, and tenderness) over the lower limbs were noted. All patients underwent aDU for the venous system and dermoscopy. Dermoscopy was done by a dermatologist with HEINE iC1dermatoscope, Germany, with the optical magnification of 15x and digital magnification of 40x and 21 mm field of view in a polarized mode. The dermotoscope was placed over the medial aspect of lower one-third of leg, and images were captured, stored, and analyzed. Both pigmentary and vascular features were noted. All patients were treated as per the standard guidelines. All guidelines as per the Declaration of Helsinki and good clinical practice guidelines were followed.

Statistical analysis

The findings of the study are presented in a descriptive format.

Results

A total of eighty CVI patients met the inclusion criteria and underwent dermoscopy. Fifty-six were males with a mean age of 58.9 years [standard deviation (SD)-12.09], and twenty-four were females with a mean age of 53.9 years (SD-12.8). Among males, eight were obese, twenty-two were overweight, and rest had normal body mass index (BMI). Among females, five were obese, fifteen were overweight, and rest had normal BMI. Twenty-four patients had no co-morbidities. Regarding co-morbidities in others, twenty-seven were hypertensive, twenty-one patients were diabetic, and ten had coronary artery disease. Eight patients gave history of hypothyroidism, four each had bronchial asthma and dyslipidemia, two patients each had previous history of stroke and allergic rhinitis, and one had HIV infection.

In this study, varicose veins were seen in 138 limbs. With respect to CVI, sixty-two patients had bilateral disease, and eighteen had one limb involvement (left 5, right 13), making a total of 142 limbs. The dermatological manifestations of CVI were mainly in the form of hyperpigmentation, eczematous changes over the medial aspect of the lower one-third of legs along with the presence of telangiectasias, reticular veins, and healed atrophic scars. Clinical examination findings and DU are summarized in Table 1.

Table 1.

Clinical examination findings and duplex ultrasound.

Clinical (C)	Number of limbs affected	Clinical findings (C)	Number of limbs affected	Etiology (E)	Number of limbs affected	Anatomical (A)	Number of limbs affected	Pathology (P)	Number of limbs affected
C 1	2	Reticular veins/spider veins (C1)	90	EC	0	AS	30	R	142
C2	18	Varicose veins (C2)	138	EP	142	AS + P	80	O	0
C3	2	Edema (C3)	33	ES	0	AP	29
C4	120	Pigmentation (C4)	120	EP + S	Nil	AD	3
C5 & C6	0	Eczema (C4)	45

Table 1 Presentation- Clinical and Duplex (DU) findings according to CEAP classification. C- Clinical classification (C1- reticular veins or spider veins, C2- varicose veins, C3- edema, C4- changes in skin and subcutaneous tissue secondary to chronic venous insufficiency, C5- healed venous ulcer, C6- active venous ulcer); E- Etiologic classification (EC- Congenital, EP- Primary, ES- Secondary); A- Anatomic classification (AS- Superficial, AP- Perforator, AD- Deep); P- Pathophysiologic classification (R- Reflux, O- Obstruction).

The standardized dermoscopic terminologies proposed by the “International Dermoscopy Society” were used to describe the dermoscopic changes in this study.¹⁰ However, some of the findings could not be accommodated within the given descriptions as suggested in the consensus statement. These findings have also been included as part of the observations of this study.

The dermoscopic findings in this study included pigmentary and vascular changes, presence of scales, and some special features.

The main dermoscopic finding of this study was accentuated reticular pigment network which was diffuse in 105 limbs and patchy in 16 limbs. The vascular structures were visible in the form of randomly distributed dotted vessels in most of the limbs (67 limbs), followed by linear curved vessels, linear curved vessels with branches, and linear vessels in decreasing order of frequency. Another dominant finding was white scales. The white scales were diffusely distributed in the majority of the limbs (56 limbs), and some (8 limbs) showed the patchy distribution of white scales. Focal white and brown structureless areas were observed in 20 and 18 limbs, respectively. Other features observed were blue-grey linear cords and blue-grey clods. Patchy yellow crust and yellow scales were seen in two limbs each with acute eczematous changes.

The frequency of main dermoscopic findings is depicted in Fig. 1. Pigmentary changes along with scaling patterns and vascular morphology on dermoscopy are shown in Fig. 2(a–d), and Fig. 3(a–e), respectively.

Fig. 1.

The frequency of main dermoscopic findings.

Fig. 2.

(a) Normal pigment network (annotated with orange circles). (b) Accentuated pigment network diffuse (annotated with yellow circles). (c) Accentuated pigment network patchy (annotated with red circles) and white scales diffuse (annotated with yellow rectangle). (d) Accentuated pigment network diffuse (annotated with yellow circles/ovals) and white scales diffuse (annotated with red ovals).

Fig. 3.

(a) Linear curved vessels with branches (annotated with green ovals). (b) Linear curved vessels (annotated with red oval) and dotted vessels (annotated with yellow ovals). (c) Blue-grey linear cords (annotated with orange ovals). (d) Dotted vessels (annotated with orange ovals), focal white structureless areas (annotated with black rectangles), and brown structureless areas (annotated with yellow ovals). (e) Blue-grey clods (annotated with green ovals).

Discussion

The exact pathophysiology of CVI has eluded us. There is still a lack of infallible clinical, hemodynamic, or radiological features which could predict the deterioration of this clinical condition.

Dermoscopy is a valuable non-invasive bedside tool in diagnosing and differentiating various dermatological diseases. The development of handheld, portable dermatoscopes using polarized light which do not require immersion fluid allow for faster screening of various dermatoses. Dermoscopic examination entails observing the morphology and distribution of vascular structures, scaling patterns, follicular alterations, morphology, and color of other structures along with certain specific clues to arrive at a conclusion. The dermoscopy findings should always be interpreted in the background of history and clinical examination of skin lesions for an accurate diagnosis.^10,12 This study was conducted to look for dermoscopic findings in CVI.

Accentuated reticular pigment network was the major dermoscopic finding of this study which was diffuse in 105 limbs and patchy in 16 limbs. The lines in the pigment network correspond to the tips of the rete ridges and are accentuated due to increased melanization of the basal layer, whereas the intervening holes correspond to the relatively less pigmented tips of the dermal papilla.¹³

In the current study, the lines in the reticular pigment network were thinner and varied from dark brown to brownish black in color, and the holes in the network were smaller and regular. The hyperpigmented areas over the lower one-third of legs were visible as accentuated reticular pigment network with a diffuse brown color of the background on dermoscopy.

The vascular structures were seen mainly in the form of randomly distributed dotted vessels, followed by linear curved vessels, linear curved vessels with branches, and linear vessels in decreasing order of frequency. Dotted vessels represent the tips of dilated vessels in dermal papilla which are vertically arranged, whereas linear vessels depict the dermal vessels that are parallel to the skin surface.¹⁰

The other findings included the presence of white scales, focal white and brown structureless areas, blue-grey linear cords, and blue-grey clods.¹⁴

It is suggested that telangiectasias appeared as linear curved vessels with and without branches and reticular veins were visible as blue-grey linear cords and clods.

The observations of the current studies could not be compared with other studies due to lack of studies on the topic. A correlation analysis between dermoscopy findings and DU report and/or clinical features was not carried out as there was the multitude of dermoscopic findings.

A literature search was done using the databases PubMed, SCOPUS, and Cochrane Library. The fields chosen were “title, keywords, and abstracts” as well as the Medical Subject Headings (MeSH) terms used for the search were as follows: dermoscopy, dermatoscopy, chronic venous insufficiency, varicose veins, telangiectasia, reticular veins, venous eczema, and stasis dermatitis. Search string was created using Boolean logic.

The search returned only two small studies on the use of dermoscopy in CVI. One report was by Zaballos et al. in 2006 on dermoscopic examination of a small series of three patients with venous stasis dermatitis which showed glomerular-like vessels, red globules, and a scaly surface.¹⁵

Another article is by Chuh A et al. on the detection and diagnosis of vascular skin lesions by dermatoscopy published in 2018.¹⁶ The authors have described the dermoscopic findings of one representative case of venous stasis from their study, which is visible as irregularly dilated vessels with dotted morphology in an erythematous background with nonhomogenous arrangement.

Thus, a comparison with aforementioned studies is not possible due to lack of clinical details and low numbers.

An attempt to group the findings has not been made as it would be premature without a proper follow-up and a large database of such findings.

The other dermatological disorder, pigmented purpuric dermatosis also presents with hyperpigmented macules on the legs and feet and requires differentiation from venous eczema, as for this condition, in our experience, many patients are referred to vascular surgeon first to rule out CVI. In a study of dermoscopy in pigmented purpuric dermatoses by Ozkaya et al., the most common findings were coppery-red pigmentation in the background and red globules followed by red dots, brown dots, and a reticular network¹⁷ which are different from the dermoscopic findings seen in CVI in our study. Hence, dermoscopy can be utilized to differentiate both the conditions.

The current understanding of CVI is far from satisfactory. Definite markers for the progression of the disease are lacking. DU is the current gold standard investigative modality, but it has limitations in its correlation with disease progression, symptoms, and skin changes. Moreover, there is no bedside tool to assess the severity of CVI. Dermoscopy merits a chance to assess its effectiveness as a bedside tool to observe the skin changes in CVI.

Limitations of the study

Ideally, dermoscopic features should be corroborated by biopsy. However, skin biopsy was avoided, as CVI patients are prone to the formation of nonhealing ulcers.

This study is an attempt to bring out the changes seen in “nonambiguous” CVI patients. The observed dermoscopic findings are presented. However, the diagnostic dermoscopic features of CVI or the features indicating the severity of CVI cannot be proposed at this stage. This study presents only a snapshot of the dermoscopic features seen in CVI. There is a need for further studies to define the evolution of these cutaneous changes, so as to determine the time frame and steps in the progression of this disease. If this is achieved by dermoscopy, then it would serve as a good bedside tool to differentiate, assess, and predict the temporal progression of CVI.

Conclusion

Dermoscopy has the potential to be a useful diagnostic modality in CVI. In this study, it identified accentuation of pigment network, dotted and linear curved vessels with or without branches, focal white and brown structureless areas, white scales, and blue-grey linear cords and clods in CVI. There is a need for further comparative longitudinal studies to delineate the role of dermoscopy in CVI.

Patients/ Guardians/ Participants consent

Patients informed consent was obtained.

Ethical clearance

Institute/hospital ethical clearance certificate was obtained.

Source of support

This article is based on Armed Forces Medical Research Committee No. 5055/2018 granted and funded by the office of Director General Armed Forces Medical Services and Defence Research Development Organisation, Government of India.

Disclosure of competing interest

The authors have none to declare.