WOUND CARE

The CHROSS Checker: a tool kit to detect

early skin changes associated with
venous and lymphovenous disease
Janice Bianchi

In patients with venous and lymphovenous disease, skin changes Arteries have thick, elastic walls,
to the lower limb(s) occur gradually, and become more serious over as blood is ejected from the heart
time if left untreated. The CHRonic Oedema Signs and Symptoms under pressure. The main arteries
(CHROSS) Checker is a tool kit consisting of an assessment chart branch into smaller vessels, the
and key cards that have been developed to help clinicians easily arterioles, then into even smaller
identify the skin changes that occur as a result of underlying venous ones, the capillaries, that reach the
and lymphovenous disease, when carrying out holistic patient tissues and organs. The walls of the
assessment. It also provides clear guidance on which compression capillaries are only one cell thick
products can be used to manage the disease type and severity of so that oxygen, glucose and other
skin change. For clinicians unfamiliar with some or all of the signs substances can pass from the blood
and symptoms listed on the CHROSS Checker chart, the key cards into the interstitial fluid (the fluid that
contain further information in the form of a photograph, definition bathes all of the cells in the body),
and cause of each sign and symptom listed. This article will describe then into the tissues and organs.
the theory behind the development of the CHROSS Checker tools
and explain how to use them in clinical practice. The capillaries are where the
arterial system of blood vessels end
and join the vessels that make up the
KEYWORDS: venous system. From the capillaries,
Assessment Skin changes Venous disease Chronic oedema blood flows into small veins that
Lymphovenous disease Compression CHROSS Checker are known as venules, which in
turn, join the large veins that return
deoxygenated blood and waste back

P
atients with disease of the This article describes how to the right side of the heart. The
venous and/or lymphatic venous and lymphovenous disease blood travelling in the veins is under
system undergo a number of results in skin changes and how to less pressure than in the arteries, so
skin changes on the lower limb(s) use the CHRonic Oedema Signs these vessels have thinner walls. As
as a consequence of underlying and Symptoms (CHROSS)Checker a result, the veins are able to expand
disease processes (Timmons and (Figure 1). This tool kit has been depending upon the volume and
Bianchi, 2008). These changes designed to raise awareness of the pressure of blood inside. For example,
can easily be detected during signs and symptoms of venous and if there is a low volume of blood and
routine cleaning and assessment lymphovenous disease, and make therefore low pressure in the vein, the
of the patients limb(s) and skin, skin changes easy to spot and veins are flat, whereas if the volume
and, once identified, can be assess in clinical practice. The kit and therefore pressure increases,
appropriately managed to slow also provides recommendations the vein expands (Starr et al, 2008;
disease progression. If venous or for the most appropriate Koeppen and Stanton, 2010).
lymphovenous disease is allowed compression hoisery to manage
to progress untreated, however, disease (according to the severity The venous network is made up of
the patient will gradually develop and type of signs/ symptoms) three types of veins (Figure 2):
more severe skin changes over time as part of an overall treatment Deep veins which lie within the
(Timmons and Bianchi, 2008). For plan to improve patient care and muscles of the arms and legs and
example, symptoms such as varicose outcomes. carry blood back to the heart
veins could eventually lead to leg Superficial veins, nearer the
ulceration and/or chronic oedema The venous system surface of the skin, which carry
if the underlying disease process is blood from the skin back to the
not addressed. Blood travels through the arteries deep veins
away from the heart, carrying oxygen Perforator veins that join the deep
and nutrients to the tissues and and superficial systems.
organs of the body, and returns via
Janice Bianchi, Independent Medical Education
Specialist and Honorary Lecturer, Glasgow the veins, carrying waste products In the lower limbs, blood
University and carbon dioxide. returning to the heart has to travel

JCN 2013, Vol 27, No 4 43

 WOUND CARE

Patient name Date:

The CHROSS checker

It is important to check for the signs and symptoms of venous and lymphovenous disease, which are listed in the chart below,
as part of a full, holistic assessment.
1. The chart should be used as a prompt to check for skin and limb changes as part of holistic patient assessment.
2. The compression products recommended should be used as part of an overall management plan, which includes medical
management of underlying disease(s), skin and wound care, and patient education.
3. Vascular status must be determined before applying compression. If in doubt, do not use and refer for specialist advice.
4. If no ticks are recorded, the limb is healthy and no action is needed, other than a good skin care regimen.
5. Intensive bandaging to reduce limb volume may be required before hosiery can be effectively used.
6. For more information on the signs/symptoms listed below, including photos and description, refer to the accompanying key cards.

1 2 3
Tick the box below if the sign/ Is oedema also present? Tick Consider application of the
symptom is reported by, or present yes or no (in the colour band compression below, depending on
on the limb of, the patient of the lowest tick in step 1) 3 severity (mild, moderate or
disease
severe) as part of management
Tired, aching, heavy legs
Activa British Standard hosiery
Spider veins Mild: Class 1 (1417mmHg)
NO
or
Prevention

Mild varicose veins

Moderate: Class 2 (1824mmHg)
Ankle flare
Mild hyperkeratosis
ActiLymph European class hosiery
Moderate varicose veins Mild: Class 1 (1821mmHg)
YES or
Hyperpigmentation
Moderate: Class 2 (2332mmHg)
Venous dermatitis
Varicose eczema Activa British Standard hosiery
Atrophie blanche Moderate: Class 2 (1824mmHg)
or
Induration NO
Early/medium

Severe: Class 3 (2535mmHg)

intervention

Severe varicose veins or

Activa Leg Ulcer Hosiery Kit
Moderate hyperkeratosis
Healed ulcer*/**
ActiLymph European class hosiery
Recurring ulcer/open ulcer*/** Moderate: Class 2 (2332mmHg)
YES or
Cellulitis*** Severe: Class 3 (3446mmHg)
or
ActiLymph Hosiery Kit

Intensive management

Lipodermatosclerosis Activa British Standard hosiery

(acute or chronic) NO
Severe: Class 3 (2535mmHg)
Chronic oedema
Lymphorrhoea (wet legs) ActiLymph European class hosiery
Moderate: Class 2 (2332mmHg)
Severe hyperkeratosis or
YES
Skin folds Severe: Class 3 (3446mmHg)
or
Papillomatosis ActiLymph Hosiery Kit
Lymphangiomata
* Activa Leg Ulcer Hosiery Kit (40mmHg) Once the correct class of hosiery has been selected for disease severity, If
**ActiLymph Hosiery Kit limb measurements do not match stock sizes, use either Credalast Velvet
***Acute cellulitis should be treated before using compression Made to Measure hosiery or ActiLymph Made to Measure flat knit hosiery

Figure 1.
Chronic Oedema Signs and Symptoms (CHROSS) Checker chart.

44 JCN 2013, Vol 27, No 4

 WOUND CARE

against gravity, which can cause it to

flow backwards. When this happens,
one-way valves present in the veins
close to prevent backflow of blood
(Anderson, 2006; 2008) (Figure 3).

The movement of blood towards

the heart from the lower limbs is
encouraged by gravity when lying
down or when the legs are elevated,
breathing and, importantly, through
the action of the calf-muscle pump
(Figure 4).

THE CALF-mUSCLE PUmP

Figure 3. Figure 4.
The blood in the leg veins is pushed One way valves in the veins of the leg Action of the calf-muscle pump.
upwards partly by the action of the prevent the backflow of blood.
foot and by the calf muscle pump as
the leg moves (Lindsay et al, 2003). balance. It carries excessive tissue HOW THE vENOUS AND
When the leg moves, the calf muscle fluid, fats absorbed from the digestive LymPHATIC SySTEmS WORK
contracts and squeezes the deep vein, system and proteins that leak from TOGETHER
opening the valves and forcing the the capillaries back to the general
blood up towards the heart. As the circulation, otherwise they would As blood passes through the capillaries
calf muscle relaxes, the valves close accumulate in the tissues as oedema a process known as filtration fluid
and create a negative pressure as (Starr et al, 2008). leaks out through the semi-permeable
the section between valves empties. walls and into the interstitial space
This negative pressure draws blood The fluid that circulates the that lies between the capillary wall
from the superficial veins, through lymphatic system is known as lymph and the tissues. This fluid is known
the perforators to refill the chamber and has an important immunological as interstitial fluid. The exchange of
ready for the next contraction of function carrying foreign particles nutrients, waste, fluid, electrolytes,
the calf muscle (Meissner et al, and cellular debris to the lymph and proteins from the vascular and
2007). This mechanism, which again nodes (Starr et al, 2008). lymphatic systems and tissue cells
sends blood upwards, is particularly occur in the interstitial fluid.
important in the legs, because Lymph capillaries are present in
when standing, blood has to travel a the tissues of all organs. They have When the venous and lymphatic
long way against gravity to return to no open end in the tissues, and systems are working correctly, the
the heart. extracellular fluid simply diffuses direction of fluid movement between
into the vessels through gaps in the the tissues and the blood and
THE LymPHATIC SySTEm capillary wall (Starr, 2008). lymphatic systems is balanced, but
when disease is present, fluid collects
The lymphatic system has an Like veins, lymph vessels also and results in oedema.
important role in maintaining fluid have smooth muscle in their walls
and flap-like valves that prevent WHy DO SKIN CHANGES
backflow. Breathing and movement of OCCUR WITH vENOUS AND
muscle helps to move lymph through LymPHOvENOUS DISEASE?
the lymphatic system.
If the valves in the veins are damaged
Lymph nodes are located at (e.g. due to surgery or trauma), or not
intervals along the lymph vessels. working correctly (e.g. due to disease),
Macrophages within the node help blood will flow back down into the
to clear the lymph of bacteria, debris veins leading to an increase in blood
and other substances. All lymph volume and pressure (Figure 5). As a
passes through at least one node result of this venous insufficiency, the
before being delivered to the blood walls of the vein stretch and the pores
stream. in the capillary wall enlarge, allowing
fluid, red cells and protein to leak
Lymph vessels converge into out into the tissues. It is this process
collecting ducts that drain into the that causes some of the signs and
veins in the lower neck. Here, the symptoms seen as skin changes, such
Figure 2. cleansed lymph fluid is returned to as hyperpigmentation and oedema
The veins of the lower limb. the circulation (Starr et al, 2008). (Figure 5). Prolonged leakage can

JCN 2013, Vol 27, No 4 45

 WOUND CARE

identifying signs of venous/lymphatic

disease during skin assessment, and
aids the user in selecting an appropriate
compression product to manage the
limb(s), according to disease severity, as
part of an overall care plan.

An article by Bianchi and Timmons

(2008) first outlined the concept of
skin changes and disease progression.
Following a consensus meeting of
clinical experts, they identified key
Incompetent skin changes that occur as a result of
venous valve
venous/lymphatic disease, and graded
them according to severity and a need
Competent for preventive, early/moderate or
Varicose veins venous valve
Varicose eczema intensive intervention. The CHROSS
Ulceration Checker takes these principles and
Induration presents them in a simplified three-
Hyperpigmentation step chart that is quick and easy to use
Oedema in clinical practice.

The CHROSS Checker should

be used as part of holistic patient
assessment, to raise awareness and
Figure 5. detection of skin changes on the
Skin changes occurring as a result of venous insufficiency. If the venous valves are lower limb. It can be used while
competent, blood is prevented from flowing backwards on relaxation of the calf muscle. assessing any patient to identify the
However, if there is valvular incompetency, blood flows backwards causing venous early signs of venous disease, the
congestion and high pressure in the veins, which ultimately result in skin changes. worsening of skin changes, or for
advanced skin changes and severe
trigger inflammatory processes in the Furthermore, these outcomes are symptoms presented for the first time.
tissue, which results in skin changes costly in terms of treatment and carry Even the most severe skin changes
such as induration, varicose eczema an increased risk of the development can be improved through correct
and lipodermatosclerosis. of complications, including cellulitis management, so it is never too late to
(Anderson, 2006; 2008). Once a identify them and intervene.
The increased volume of blood patient contracts cellulitis, they are
also puts extra pressure on the at increased risk of further episodes, For clinicians unfamiliar with
perforating and superficial veins. As which can result in admission to any of the conditions listed on the
these veins stretch, their valves do hospital and associated spiralling costs chart, CHROSS Checker key cards
not close properly so they can no (Clinical Resource Efficiency Support are available, providing further
longer prevent a backflow of blood. Team [CREST], 2005). information on each of the conditions,
The volume of blood within the veins including a photograph of the skin
increases further, raising blood pressure Such severe signs and symptoms change, a description of the condition,
in the vein, causing it to stretch and of venous and/or lymphatic disease a brief explanation of its cause (Figure
resulting in more fluid leaking out generally do not occur out of the blue, 6) and, on its reverse, the compression
into the tissues. Stretching of the veins but begin as mild skin changes that management strategy recommended
leads to their becoming varicose. The can become worse with time if the (Figure 7). The signs/symptoms listed
lymphatic system then becomes unable underlying failure of the venous and on the key cards are colour-coded
to cope with the extra volume of fluid, lymphatic systems is left unchecked. according to their presentation on
leading to a worsening of oedema and However, if these skin changes are the chart (green for those requiring
chronic high blood pressure in the recognised as signs that the venous preventative management, orange for
vein (venous hypertension). This is the and lymphatic systems are not working eary/medium intervention and red
main underlying cause of venous leg normally, further assessment of the for intensive management), for quick
ulceration and lymphovenous oedema. patient will allow a management plan referencing.
to be put in place that prevents or
Severe skin changes, such as leg delays the worsening of the condition. When using the CHROSS
ulceration, or swollen or wet leaky Checker in conjunction with holistic
legs, can have a huge negative impact THE CHROSS CHECKER patient assessment, the clinician
upon patient quality of life, and can can systematically examine the limb
lead to social isolation and depression The CHROSS Checker chart (Figure 1) for skin changes and implement
(Persoon et al, 2004; Jones, 2008). allows an easy three-step approach to treatment if appropriate.

46 JCN 2013, Vol 27, No 4

 WOUND CARE

reverse side of the key cards (Figure 7),

so that both parts of the kit can be used
Ankle flare
together or separately in practice.
Ankle flare

Definition: WHY USE COMPRESSION TO

Distension of the small veins of the foot, MANAGE SKIN CHANGES?
around the ankle
Compression therapy is a key
Cause:
Chronic venous hypertension component of managing venous and
lymphovenous disease (Hardy,
Action: 2010). It enhances the functioning of
Prevention: skin care, compression hosiery the calf muscle pump and also helps
to close faulty veins on calf muscle
relaxation, preventing the backflow
Figure 6. of blood. As a result of these actions,
CHROSS Checker key card (front) showing information on ankle flare. it improves venous return and helps
to redistribute blood and fluid from
the lower limb back into the central
sections of the body, reducing venous
Hosiery recommendation
congestion and blood pressure (Torra i
Bou and Moffatt, 2008). Compression
has been seen to relieve thesymptoms
With oedema Without oedema
of venous and lymphovenous disease
ActiLymph European Class hosiery Activa British Standard hosiery and accelerate the healing rate of
Mild disease: Class 1 (1821mmHg)* Mild disease: Class 1 (1417mmHg)** venous ulcers, thereby improving the
or or general skin condition of the patient
Moderate disease: Class 2 (2332mmHg)* Moderate disease: Class 2 (1824mmHg)** (Moffatt, 2007). It is also known that
*If limb measurements do not match stock sizes, **if limb measurements do not match stock sizes, compression can improve lymphatic
use ActiLymph Made to Measure hosiery use Credalast Made to Measure hosiery transport and re-absorption of
lymph into the lymphatic system
(Foldi et al, 2006).
Figure 7.
CHROSS Checker key card (reverse) showing information on ankle flare. In limbs with chronic oedema,
and/or leg ulceration, compression
HOW TO USE THE tick, move across into the step 2 bandaging (most commonly short-
CHROSS CHECKER column. Step 2 confirms the presence stretch [inelastic]) is usually used to
or absence of chronic oedema. In the reduced limb volume and promote
Step 1 example provided (Figure 8), ankle flare healing. Once limb volume has
As part of holistic assessment, the is present without oedema, so the no reduced and/or ulceration healed,
patients skin and limb should be arrow in the green-coloured box should compression hosiery is commonly
examined for the signs listed on be checked and followed across into the prescribed to maintain limb volume
the CHROSS Checker chart. If any step 3 column (Figure 8). and shape, and to prevent ulcer
are present, they should be ticked recurrence (Hardy, 2006). If hosiery is
accordingly. For example, if the limb Step 3 not used following intensive therapy
presents with ankle flare, this box Step 3 is where a recommendation is episodes, the improvements gained
should be ticked in column 1 made of the most appropriate hosiery to may be compromised (Timmons and
(Figure 8). If the user requires further manage the skin changes seen, as part Bianchi, 2008). For patients with limbs
information, the CHROSS Checker key of an overall care plan. In the example that do not fit standard sizes, made-to-
cards can be consulted of ankle flare without oedema, given in measure products are available.
(Figures 6 and 7). Figure 8, the recommendation would be
Activa British Standard hosiery class 1 COMPRESSION HOSIERY
If multiple signs and symptoms (1417mmHg) if mild disease is present,
are present, the tick at the lowest or class 2 (1824mmHg) for moderate There now exists a large range of
point of the chart represents the disease. Although the cards provide compression hosiery garments which
most severe condition and it will a guide, it is the responsibility of the can be used at all stages of venous and
fall into a coloured background that clinician to use their judgement and lymphatic disease development. For
indicates if preventative (green), expertise to grade the severity of disease patients with early stage skin changes
intermediate (orange), or intensive present, and make an appropriate and no oedema who require preventive
(red) management is required. hosiery selection based upon this. treatment, the use of British Standard
hosiery is appropriate. British Standard
Step 2 These compression hosiery is lighter and cosmetically
Within the colour band of the lowest recommendations are repeated on the acceptable, with many different styles

48 JCN 2013, Vol 27, No 4

 WOUND CARE

Tick the box below if the sign/ Is oedema also present? Consider application of the compression
symptom is reported by, or present Tick yes or no (in the 3
below, depending on disease severity (mild,
on the limb of, the patient colour band of the moderate or severe) as part of management
lowest tick in step 1)
Tired, aching, heavy legs
Activa British Standard hosiery
Spider veins Mild: Class 1 (1417mmHg)

Prevention Mild varicose veins
NO or
Moderate: Class 2 (1824mmHg)
Ankle flare

Mild hyperkeratosis
ActiLymph European class hosiery
Moderate varicose veins Mild: Class 1 (1821mmHg)
YES
Hyperpigmentation or
Moderate: Class 2 (2332mmHg)
Venous dermatitis
Figure 8. Varicose eczema
The three steps to using the CHROSSAtrophie
Checkerblanche
chart to get a hosieryrecommendation for a patient with ankle
Activa
flareStandard
British and no hosiery
oedema.

Class 2 (1824mmHg)
may consist NO or
and colours available to help with Indurationskin changes present, of Wound Management Association (EWMA).
Class 3 (2535mmHg)
patient concordance (Bianchi and Severe varicose medicalveinsmanagement, skin and wound Focus Document: Lymphoedema bandaging
Timmons, 2008). care, exercise,
Moderate hyperkeratosis manual lymphatic in practice. London: MEP Ltd: 24
drainage (MLD) and patient education. Green T (2007) Legulcer management in
If oedema is diagnosed, European Healed ulcer* ActiLymph European class hosiery
patients with chronic oedema. Wound

Class 2 (2332mmHg)
Class hosiery garments can be usedRecurring CONCLUSION
ulcer/open ulcer*/** YES Essentials 2: 4658 or
to prevent recurrence or deterioration,
Cellulitis*** Hardy D (2006)ClassManaging long-term
3 (3446mmHg)
once limb volume has been reduced The CHROSS Checker tool kit (Figure conditions, non cancer-related
using bandaging. The action of Chronic oedema
9) provides a quick and easy way to lymphoedema. Br J Nurs 15(8): 44452
European Class garments is more likelyLymphorrhoeaevaluate skin changes as part of holistic
(wet legs) Hardy D (2010) Chronic
ActiLymph oedema class
European and associated
hosiery
to encourage lymphatic movement Severe hyperkeratosis
patient assessment, and provides complications. Wounds UK
Class 3 (2332mmHg)6(4): 13845

and reabsorption of the lymph in the clear guidance on the selection of YES Jones JE, Barr W, RobinsonorJ (2008) Impact of
vessels and contain oedema, due toSkin folds compression products to delay disease exudate and Class
odour3 from chronic venous
(3446mmHg) leg
their having greater stiffness that comes progression in patients
Papillomatosis with venous ulceration. NursMadeStandard 22(45): 5361
to Measure

from the yarns and the knitting process and lymphovenous dysfunction.
Lymphangiomata JCN Koeppen BM, Stanton BA (eds) (2010) The
used during manufacture (Bianchi and cardiovascular system. In: Berne and Levy
Activa British Standard hosiery
Timmons, 2008). Patients with limbsLipodermatosclerosis Physiology. Mosby Elsevier, Philadelphia: 287415
Class 3 (2535mmHg)
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that are severely swollen may not fit(acute or chronic) NO Lindsay ET, Muldoon J, Hampton or S (2003)
into standard hoisery sizes and will Short stretchClass
compression
3 (2535mmHg) and the
bandages
require made to measure garments. Anderson I (2006) Aetiology, assessment and foot pump: theirMade relationship
to Measure to restricted
These are usually constructed using management of leg ulcers. Wound Essentials mobility. J Wound Care 12(5): 1858
thicker and firmer material that helps 1: 2037 Meissner MH, Moneta G, Burnand K, et al
to effectively contain the limb. Anderson I (2008) Understanding chronic venous (2007) The haemodynamics and diagnosis of
hypertension. Wound Essentials 3: 2032 venous disease. J Vasc Surg 46: 4s24s
For all patients with venous or CREST (2005) Guidelines on the management Moffatt C (2007) Bandaging and compression
lymphovenous disease, compression of cellulitis in adults. Available online at: therapy. In: Moffatt C, Martin R, Smithdale
should be used as part of an overall www.crestni.org.uk R (2007)Leg Ulcer Management. Blackwell
treatment plan which, depending on Foldi E, Junger M, Partsch H (2006) The science Publishing, Oxford
the underlying medical condition and of lymphoedema bandaging. In: European Persoon A, Heinen MM, van der Vleuten CJ, de
Rooij MJ, van de Kerkhof PC, van Achterberg
T (2004) Leg ulcers: a review of their impact
on daily life. J Clin Nurs 13(3): 3414
althy Starr C, Taggart R, Evers C, Starr L (2008)
good
Circulation. In: Biology: The Unity and

CHROSS Checker Diversity of Life. Brooke Cole, Belmont:

287415
Timmons J, Bianchi J (2008) Disease
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...with a little bit of detective work. Torra i bou JE, Moffatt C (2008) Understanding
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Figure 9. Problems of the Lower Limb: An Holistic
The CHROSS Checker tool kit is available on request from Activa Healthcare. Approach. Wounds UK, Aberdeen

JCN 2013, Vol 27, No 4 49

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.