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This Guidelines summary of the British Lymphology Society’s red legs pathway covers practical information on clinical decision-making for healthcare professionals managing red legs.

Explanatory notes for bold terms in the red legs pathway are covered in the main text.

View this summary online at guidelines.co.uk/456451.article

Red legs pathway

BLS red legs pathway v4

For explanatory notes on the terms in bold, refer to the section below.

Explanatory notes


  • An acute bacterial infection that can affect any part of the body, but can commonly affect the leg (unilateral); there is often a rapid onset within hours, sometimes less time if the patient already has an underlying lymphoedema.

Bilateral leg redness

  • Can be acute but is more likely to be chronic; often present for weeks and months, and in some cases years. Chronic redness can also be seen following cellulitis (post-cellulitic staining). Obese, immobile, and elderly people are at increased risk. Always treat the underlying conditions, for example, athletes’ foot.


  • Can be acute or chronic. The acute or chronic exacerbation is caused by venous hypertension, which gives rise to bilateral lower leg redness
  • In acute cases, there may be associated warmth, pain, and swelling
  • In chronic cases, there may be dull redness, normal skin temperature, and little or no pain. These are the patients who are often treated with antibiotics with no benefit. The only effective management is compression, which can give pain relief once fitted.

Varicose eczema/gravitational dermatitis

  • Varicose eczema/gravitational dermatitis is caused by increased pressure in the leg veins. When the small valves in the veins fail, venous reflux is seen, which can cause fluid to leak into the surrounding tissue
  • It is thought that varicose eczema may develop as a result of the immune system reacting to this fluid. The skin can be itchy, red, swollen, dry, and scaly, and there may be associated haemosiderin staining, lipodermatosclerosis, and atrophie blanche
  • Chronic skin discolouration in a patient is likely venous insufficiency. This is extremely common and often mistaken for cellulitis; however, antibiotics are not indicated in chronic venous changes. There are likely haemosiderin deposits, spider veins, and generalised erythema in a non-hot leg, which is usually bilateral.

Contact dermatitis

  • If suspected, initiate patch testing.

Fungal infection

  • Use antifungal cream daily, for example, terbinafine hydrochloride 1% cream. Encourage thorough drying, especially in the toes/folds and creases. Use separate towels, wear clean socks/compression hosiery daily, and disinfect the inside of shoes when not worn.

Redness/rash and intertrigo

  • Redness/rash in the feet and intertrigo in deep skin folds in the legs, especially in obese patients. Encourage daily washing, thorough gentle drying with tissue if necessary, and use of antifungal cream. In both conditions, the patient should see a GP if symptoms do not improve.


  • Drugs that can exacerbate or cause lower limb oedema may be associated with redness at the onset of oedema, due to an inflammatory response. Pregabalin and, to a lesser extent, gabapentin, corticosteroids, calcium channel blockers, non-steroidal anti-inflammatory drugs, and medications for Parkinson’s disease are all possibilities.

Underlying medical conditions

  • Underlying medical conditions that cause increased oedema, and those where there is venous hypertension (such as heart failure) may lead to some degree of redness. Perform echocardiogram, N-terminal pro b-type natriuretic peptide, and urea and electrolytes, as clinically indicated.

Venous hypertension—varicosities

  • High blood pressure inside the vein: many people with varicose veins in the legs have no symptoms, whereas others have pain or aching, feel swollen and heavy, or itchy. Consider referral to vascular services.

Phlebitis/superficial thrombophlebitis

  • Inflammation of a vein: symptoms include painful hard lumps underneath the skin, causing redness.

Topical steroids

  • Topical steroids are likely to be helpful. Potent steroid ointment can be applied to affected areas daily for maximum of 2 weeks. After this, reduce potency of steroid ointment and continue for a further 2 weeks. Always apply steroid ointment 30 minutes after moisturising.

Further resources


Full guideline:

British Lymphology Society. Red legs pathway. BLS, 2020. Available at: thebls.com/documents-library/red-legs-pathway.

Published date: August 2020.


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