Understanding Lipodermatosclerosis, causes and management- Dr Pradeep Mahajan

Venous insufficiency refers to a condition where there is an impaired flow of blood from the veins of the leg to the heart. Varicosities are most commonly heard of, which, as we all know are swollen veins in the legs, generally seen in those who stand for prolonged periods. Lipodermatosclerosis is a similar condition that refers to skin changes in the lower portion of the legs; however, is not related to varicose veins. The condition is a form of panniculitis (sclerosing panniculitis), which means inflammation of the layer of fat under the skin.

Lipodermatosclerosis is a progressive fibrotic process that gradually leads to hyperpigmentation and induration (hardening) of skin. The exact cause of the condition is unknown but may be assumed to be caused due to raised pressure in the leg veins (venous hypertension or venous incompetence). This may cause fluid and proteins to leak out of the veins ultimately leading to fibrosis and inflammation of the underlying skin. Possibly, there could be a lack of oxygen and nutrient delivery to the tissue as well. There is limited data regarding the prevalence of the condition. Nonetheless, among the other conditions associated with venous insufficiency such as varicose veins, venous eczema; lipodermatosclerosis is relatively uncommon.

Symptoms

The patient may experience pain, swelling in the legs, and notice hardening and discoloration of the skin. Itching, scaling of the skin may also be seen. Acute lipodermatosclerosis presents as painful, erythematous, purple indurated plaques – well demarcated from normal skin –possibly with white scale. Chronic conditions may reveal tapering of legs above the ankle, resembling an inverted champagne bottle. In long-standing cases, ulcerations may be seen.

Causes

Obesity has been reported as one of the chief causes of lipodermatosclerosis. Being overweight or obese exerts pressure on the vessels, especially those associated with weight-bearing structures; thereby leading to damage in patency over time. Therefore, weight management/lifestyle modification is the main aspect to consider in the treatment of this condition.

Do's and Don'ts

Conventionally, the chief therapeutic approach is graduated compression. Pharmacological and surgical interventions have also been indicated, with varying results. Patients should be instructed to avoid standing or sitting for prolonged periods. Leg elevation along with regular physiotherapy exercises will aid in improving the blood flow. Some patients may be advised medicines to prevent clotting of blood (aspirin etc.). However, in severe cases, surgery of the affected vein (s) may be indicated.

Management

A newer, more effective form of treatment for lipodermatosclerosis is cell-based therapy. Mesenchymal cells in our body have the capacity to self-renew and possess anti-inflammatory, immunomodulatory properties. When these cells are implanted in the area surrounding the affected vein, they are capable of differentiating into vascular endothelial cells and smooth muscle cells. Through this, we can achieve thickening of the layer of collagen and also improve the elasticity of the vein walls. Mesenchymal stem cells also have the ability to migrate to the site of injury or inflammation and participate in the regeneration of damaged tissues. These cells stimulate proliferation and differentiation of surrounding cells and promote recovery of injured cells through growth factor secretion and matrix remodeling. Supplementary treatment with hyperbaric oxygen ensures adequate perfusion of hypoxic tissues, which facilitates healing.

A case of lipodermatosclerosis successfully managed with cell-based therapy

78 years old female patient, Mrs. Lalita, reported to our hospital in May 2017 with complaints of pain and swelling in both legs (left more than right) for 2 years. She also had lesions on her legs with suppuration. The patient was diagnosed as a case of Lipodermatosclerosis with vasculitis before 2 years. She also complained of itching all over the body with occasional fever, nausea, and loss of appetite for 2 weeks. The patient is known hypertensive and in under medication for 10 years.

The patient underwent three sessions of cell-based therapy with cells and growth factors sourced from the patient's own body, which were administered intravenously as well as in areas surrounding the lesions.

Improvement in the patient's condition was noticed as early as 3 days following cell-based therapy and results have been maintained over a period of 6 months. The patient is now able to walk comfortably and does not have pain or swelling in her legs. Indurated and erythematous lesions have healed with minimal scarring and softening of fibrotic areas is observed. Eczematous areas have healed and the patient no longer has itching sensation.

Dr Pradeep Mahajan is a urologist and the Chairman and Managing Director of StemRx Bioscience Solutions Pvt Ltd.