1. Establish whether leg symptoms really are venous in origin.
In a patient with leg symptoms ask what the symptoms are and when they occur. Heaviness, itching and aching may be due to varicose veins, especially if they are worse at the end of the day and relieved by elevation.1 Suspect a musculoskeletal cause for sudden sharp pains, pain on movement and pain in the groin. Suggest a trial of compression hosiery – if it helps, symptoms are probably venous.
2. Tease out patients’ specific worries.
Patients may have general concerns about the future, or specific fears about ulcers, deep vein thrombosis, bleeding or even amputation.2 Any significant skin changes should prompt referral, but in the absence of skin changes there is seldom any reason to anticipate serious problems and patients can be strongly reassured and offered advice about compression hosiery and moisturising.
3. Avoid Doppler tests when making referral decisions.
Doppler tests of the veins are unhelpful in making referral decisions. Their only place is in checking arterial signals and pressure at the ankle in patients with ulcers or other indications – for example, some patients with diabetes who need compression.
4. Eczema with varicose veins is a warning sign.
Varicose eczema is often the result of venous hypertension caused by incompetent venous valves. It sometimes causes severe itching and is a warning sign for progressive skin damage. Treat with intermittent use of steroid cream followed by regular moisturising. Consider referral for specialist assessment of the veins. A below-knee compression stocking is a useful interim measure.
5. Look for skin pigmentation around the ankle.
Lipodermatosclerosis can present as redness or brown pigmentation above and around the ankle, with hardness of the fatty layer beneath. It indicates serious damage caused by venous hypertension and the patient is at risk of ulcers. Prescribe a class II, below-knee, graduated compression stocking, advise twice daily use of moisturiser and consider referral for specialist assessment. Patients with typical lipodermatosclerosis or ulcers may have significant venous incompetence even if they have not got obvious superficial veins.
6. Be aware of ‘inflammatory liposclerosis’.
This condition is not in the books, but is very real and can be distressing. An area of lipodermatosclerosis around the ankle becomes red, inflamed and often tender and painful. It is usually misdiagnosed as thrombophlebitis, but consists of inflamed, hard subcutaneous tissue, not varicose veins. Its cause is not well understood. Treatment is with moisturiser, NSAIDs and strong analgesics if required. Treating the underlying veins generally settles this condition.
7. Don’t give antibiotics for thrombophlebitis.
Thrombophlebitis causes varicose veins to become hard, tender and red, but this is inflammation and not infection. Treatment should consist primarily of NSAIDs, not antibiotics. There is uncertainty about whether phlebitis poses any substantial risk of deep vein thrombosis – it usually doesn’t, but many vascular specialists would duplex scan the deep veins if phlebitis starts to extend up the thigh.
8. Look for other venous blemishes.
Most blemishes are cosmetic only and it is worth explaining this to patients. The most common are: normal veins showing up in people with pale skin; little reticular veins, typically behind the knee; thread veins, which often cause needless concern if they are around the ankle; and thin-walled dark blue or black ‘blebs’ with thin skin over an obvious vein, which are at risk of bleeding if traumatised and so are worth treating.
9. Don’t dismiss cosmetic concerns.
For many people, varicose veins cause no symptoms and appearance is their main worry – often understandably. But as varicose veins can cause considerable reduction in quality of life, there is good evidence that treating people with symptoms is clinically and cost-effective.3,4 Recent referral restrictions are not based on lack of effectiveness, but on affordability.
10. Most treatments are similar in efficacy.
The range of treatments now available for varicose veins can be confusing. They include foam sclerotherapy, thermal ablation by radiofrequency or laser, and surgery – and combinations of these. Evidence suggests the effectiveness of all these techniques is similar.5,6 They all work well in the medium term, but some people develop more veins over the years. Much of the information on the internet is from clinics with an interest in promoting particular treatments. I have published information for patients that tries to be unbiased.7 Most specialist units offer a choice of treatments, and informed patient choice is important in management.
Professor Bruce Campbell is a consultant vascular surgeon at Royal Devon and Exeter Hospital
References
1 Bradbury A, Evans C, Allan P et al. What are the symptoms of varicose veins? Edinburgh vein study cross-sectional population survey. BMJ 1999;318:353-6
2 Campbell W, Decaluwe H, MacIntyre J et al. Most patients with varicose veins have fears or concerns about the future, in addition to their presenting symptoms. Eur J Vasc Endovasc Surg 2006;31:332-4
3 Michaels J, Brazier J, Campbell W et al. Randomised controlled trial comparing surgery with conservative treatment for uncomplicated varicose veins. Br J Surg 2006;93:175-81
4 Ratcliffe J, Brazier J, Campbell W et al. Cost-effectiveness analysis of surgery versus conservative treatment for uncomplicated varicose veins in a randomised controlled trial. Br J Surg 2006;93:182-6
5 Nesbitt C, Eifell R, Coyne P et al. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Sys Rev 2011;10:CD005624
6 Rasmussen L, Lawaetz M, Bjoern L et al. Randomised clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011;98:1079-87
7 Campbell B. Understanding varicose veins. Family Doctor Publications. 2011
