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Scarring of the skin and fat

Lipodermatosclerosis (LDS) is a medical condition that affects the skin just above the ankles in patients with long-standing venous disease, resulting in chronic venous insufficiency. It is classified as a form of panniculitis (inflammation of subcutaneous fat).
LDS literally means “scarring of the skin and fat” and is a slow process that occurs over a number of years. It affects the inside surface of the ankle. Over time, the skin becomes brown, smooth, tight and often painful. People with chronic vein problems (venous insufficiency or venous stasis) and constriction of blood flow to this area are those generally affected by the disease.

What causes LDS?

The precise mechanism of LDS is not fully understood, but the root cause is known. LDS is caused by an excessively high venous pressure in the subcutaneous veins in the lower leg. This high venous pressure is the result of two things:

1. The upright posture
2. An inefficient calf muscle pump

Lipodermatosclerosis (LDS) usually happens over a period of years but in rare instances has been acute in onset. It predominantly strikes middle-aged
people and those suffering with obesity.

Diagnosing LDS

Diagnosing LDS is based mainly on clinical presentation. A dermatologist will sometimes order an MRI (magnetic resonance imaging) scan or ultrasound to establish the extent of the disease. Blood tests are rarely ordered to aid in diagnosis but sometimes, coagulation is tested.
The classic lesions that characterise LDS include the following:

• Early lesions: Infiltration of lymphocytes (white blood cells) and tissue death in fibrous tissue dividing the fat (septa).
• Intermediate lesions: A mix of lymphocytes and new fibrous tissue in the septa.
• Advanced lesions: Severe fibrosis in the fat, with reduced or absent inflammatory cells.

Complications

The complications of LDS are serious and should not be overlooked. Leaving LDS untreated, an individual can acquire a venous leg ulcer. Such an ulcer is caused by the loss of skin and tissue due to poor circulation in the legs. This can be avoided by treating the underlying cause of the disease, such as improving calf muscle function or restraining from standing on your feet for too long.

Treatment

Treating LDS is a matter of controlling the underlying causes of the disease, as well as much emphasis on compression therapy to correct venous insufficiency.
Com­pres­sion therapy includes either tight bandaging around the affected area or the use of compression stockings. These are designed to exert a greater pressure on the skin at the ankle and less pressure on the calf. The pressure exerted by the socks helps to counteract the excess pressure in the veins that is the result of standing and walking. However, the compression socks do not cure the underlying problem and once prescribed, they normally have to be worn for life.
If the LDS is partially or wholly the result of severe varicose veins, then surgery to remove the abnormal veins does at least offer the potential for cure. Other treatment options include:

• vein surgery
• weight loss
• medications that increase
blood flow
• ultrasound therapy
• pain-relievers

It is always best to communicate progress with a dermatologist, so he can prescribe treatment that works for you and make changes in treatment when necessary.
Unless the underlying cause of LDS is treated, then the patient is at high risk of developing a painful and potentially chronic venous leg ulcer. Once LDS is established, the skin has been permanently and irreversibly damaged, and treatment at that stage can only hope to prevent progression of LDS to an open leg ulcer. A patient with LDS warrants referral to a vascular surgical clinic for full assessment of the venous system.
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