Understanding Varicose Veins: Signs, Symptoms, Key Points, Differentials, and Management
Varicose veins are characterized by visible dark-blue or purple veins, leg swelling, and persistent leg aching. To ensure proper identification, differentials include distinguishing varicose veins from conditions like deep vein thrombosis and arterial insufficiency. Effective management strategies encompass lifestyle adjustments like regular exercise and leg elevation, alongside wearing compression stockings and avoiding prolonged standing. For more severe cases, medical interventions like sclerotherapy, endo-venous ablation, or surgical procedures may be considered. This table serves as a valuable reference for understanding, diagnosing, and treating varicose veins comprehensively.
The table provides a comprehensive overview of the terminology associated with varicose veins, Venous Clinical Severity Score (VCSS) and CEAP classification, highlighting the key signs and symptoms, differentials for accurate diagnosis, and available management options. Various other publications can be found here for broadening the knowledge related to varicose veins.
| Sign and Symptoms | Location | Synonym | Size (if any) | Description | Sign of Chronic Venous Insufficiency |
|---|---|---|---|---|---|
| Telangiectasia | Merging of dilated intradermal venules | Synonym - Spider veins, Hyphen webs, or Thread veins | Vessel Diameter < 1 mm | ||
| Reticular veins | Dilated intradermal venules Often tortuous | Synonym - blue veins, intradermal varices, or venulectasias | Vessel Diameter 1-3 mm | ||
| Varicose veins | Subcutaneous dilated veins Generally tortuous | Synonym - varix, varices, or varicosities | Vessel Diameter ≥ 3 mm in upright position | ||
| Corona phlebectatica | Medial or lateral aspects of the ankle and foot | Synonym - Malleolar flare or ankle flare | Fan-shaped pattern of numerous small intradermal veins | Early sign of advanced venous disease | |
| Odema | Around the ankle region (peri-malleolar area), but it may extend to the leg and foot Restricted to a limited area drained by capillaries that empty directly into the varicose or incompetent veins. | Standing job, gradually increases towards the end of day. | Most commonly the first manifestation of chronic Venous insufficiency | ||
| Pigmentation | Small spots to Large Ulcerations | Brownish darkening of the skin caused by extravasated blood | Sign of venous stasis disease (Chronic Venous Disease) |
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| Venous (stasis) Dermatitis | Around the ankle region (peri-malleolar area) | Synonym - Stasis dermatitis, Stasis Eczema, Varicose Eczema, Stasis Syndrome, hypostatic eczema, congestive eczema and dermatitis hypostatica | Sharply marginated, erythematous, crusted plaque | ||
| Eczema | Synonym - venous dermatitis or stasis dermatitis. | Erythematous dermatitis that may develop into a blister or scaling eruption on the skin of the leg. | Usually associated with chronic venous disease (CVD) | ||
| Lipodermatosclerosis | Can lead to contracture of the Achilles tendon. | Localized chronic inflammation and fibrosis of the skin and subcutaneous tissues. | Indicative of severe CVD. | ||
| Atrophie blanche | Synonym - white atrophy | Circumscribed, whitish, and atrophic skin areas surrounded by dilated capillary spots and occasionally hyperpigmentation and telangiectasias. | Sign of Severe CVD | ||
| Pain | Dull, Vague, located at medial aspect of the leg Long standing jobs Pain during exercise Pregnancy | Sign of Chronic Venous insufficiency | |||
| Venous ulcer | Most commonly found around the ankle | Chronic skin defect that fails to heal spontaneously due to CVD. | Sign of Severe CVD/End-stage manifestation |
| Sign and Symptoms | Other Keypoints | Symptom Specific Management (If Any) |
|---|---|---|
| Telangiectasia | ||
| Reticular veins | ||
| Varicose veins | ||
| Corona phlebectatica | ||
| Odema | 1. Noticeable increase in fluid volume in the skin and subcutaneous tissue. 2. Identified by indentation when pressure is applied. 3. Incidence of Leg oedema may not related to extent of varicose vein disease. 4. True ‘pitting’ edema is rare, perhaps resulting from increased dermal fibrosis present in lipodermatosclerosis. | 1. Main goal is to prevent superficial venous hypertension and associated trauma 2. Leg Elevation 3. Systemic Diuretics 4. Localized compression bandaging 5. Venoactive drugs such as flavonoids, micronized purified flavonoid fraction (MPFF), and horse chestnut seed extract to relieve pain and swelling due to CVI |
| Pigmentation | 1. LipoDermatoSclerosis and Venous Leg Ulcer are always accompanied by hemosiderin deposit 2. Lichen Aureus - Acute and eruptive cutaneous pigmentation due to extensive venous hypertension 3. Elongated, distended vascular system is more susceptible to trauma than a normal vessel and minor blunt injuries may cause rupture of vascular wall with extravasation of erythrocytes into the cutis. 4. Histologically Early - cutaneous hyperpigmentation is increased melanin Advance - extravasated erythrocytes and hemosiderin-laden macrophages interspersed between dilated and tortuous capillaries | Correction of underlying venous hypertension (sclerotherapy, EVLT, surgery) including graduated compression stockings and leg elevation |
| Venous (stasis) Dermatitis | 1. Not true stasis rather venous hypertension 2. Mimic neoplasm 3. More frequent in women, obese people, middle-aged men and women and people with history of DVT and thrombophlebitis | |
| Eczema | 1. It often appears near varicose veins but can also occur elsewhere on the leg. 2. Can be triggered by sensitization to local therapy. | |
| Lipodermatosclerosis | 1. May be preceded by diffuse inflammatory edema of the skin, known as hypodermitis. 2. Does not involve lymphangitis, lymphadenitis, or fever, which distinguishes it from erysipelas or cellulitis. 3. Severe pain with patient unable to tolerate compression therapy | Stanozolol - Successful in reducing the pain, induration and cutaneous thickening. Dose range - 2-10 mg BD x 8 weeks-6 months (rarely beyond 6 months) Response is seen within 3-4 weeks and maximum improvement can be seen within 3 months MOA - unknown but suggested to be due to decreased levels of tissue plasminogen activator inhibitor Anabolic steroid with fibrinolytic property Precautions: Temporary elevation of Liver transaminases and depression of HDL Blood pressure check (weekly for 2-3 weeks then monthly) LFT - every 3-4 weeks |
| Atrophie blanche | 1. Intermediate stage between Venous Dermatitis and Varicose ulceration. 2. Histologically capillaries are detected at border of lesion with apex oriented towards avascular center | 1. Treatment of venous hypertension 2. Antifibrinolytics (aspirin, dipyridamole) 3. Anti-inflammatory agent (dapsone) 4. Pentoxifylline |
| Pain | Pressure on dense network of somatic nerve fibers present in subcutaneous tissue adjacent to affected nerve. Dilated vein compressing adjacent nerves Lactic acid accumulation - due to retrograde, circular and slower venous blood flow clearance. | 1. Systemic Hydroxyrutosides (Paroven)- decrease inflammation of vein wall 250 mg TDS or QID 2. Venoactive drugs such as flavonoids, micronized purified flavonoid fraction (MPFF), and horse chestnut seed extract to relieve pain and swelling due to CVI |
| Venous ulcer | 1. Most common chronic leg wound is venous leg ulcer. 2. Malignant Transformation can occur in patients with chronic leg ulcer. 3. Most common carcinomas - Squamous and basal cell. 4. Most common sarcoma - Fibrosarcoma, Osteosarcoma and Angiosarcoma | Pentoxifylline - 400 mg orally TDS or micronized purified flavonoid fraction (MPFF) in combination with compression to accelerate the healing of venous ulcers |
2. Sclerotherapy: Treatment of Varicose and Telangiectatic Leg Veins 6th edition