Venous eczema mimicking cellulitis — SCE Geriatric Medicine MCQ

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ModerateDermatologyVenous eczema mimicking cellulitisSCE Geriatric Medicine

An 83-year-old woman has a painful red lower leg with chronic oedema. She has bilateral varicose eczema, no fever, CRP 12 mg/L and normal WCC. The erythema is bilateral, itchy and scaly; previous episodes labelled cellulitis did not improve with antibiotics. What is the most likely diagnosis?

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Correct answer: C — Venous eczema with lipodermatosclerosis

Explanation lettering: C = shown as A · D = shown as B · A = shown as C · E = shown as D · B = shown as E

The correct answer is A (Venous eczema with lipodermatosclerosis). The clinical presentation—bilateral, chronic, itchy, scaly erythema in a patient with established varicose eczema, zero systemic signs, and crucially, failure to respond to prior antibiotics—is pathognomonic for non-infectious venous dermatitis. Cellulitis (B) is almost always unilateral, presents acutely with fever and raised WCC, and responds to antibiotics within days. The normal inflammatory markers and absent fever eliminate necrotising fasciitis (C). Bilateral DVT (D) would present with oedema and pain but not eczematous scaling or pruritus. Gout (E) is joint-centred and acutely inflammatory. Lipodermatosclerosis is skin fibrosis and pigmentation change resulting from chronic venous hypertension and often coexists with varicose eczema in advanced chronic venous disease. The antibiotic failure is key: it excludes infection entirely and points to an inflammatory dermatological diagnosis.

Reference: NHS – Varicose eczema: https://www.nhs.uk/conditions/varicose-eczema/; NHS Knowledge Now – Varicose Veins (chronic venous disease classification): https://nwknowledgenow.nhs.uk/content/varicose-veins/; South & West Devon NHS Formulary – Varicose Veins (2024–2026)