Login
Search

Search
Search

Varicose Veins and Venous Ulcers

NICE CKS Varicose Veins. Last revised: Sep 2024. NICE CKS Venous leg ulcer. Last revised: Oct 2024.

Background Information

Chronic venous insufficiency: functional changes that occurs due to persistent venous hypertension.
 

Varicose veins and venous leg ulcer can occur secondary to chronic venous insufficiency:
  • Varicose veins: dilated tortuous superficial veins (most commonly found in the lower limb)
  • Venous leg ulcer: break in the skin which has not healed within 2 weeks, in the presence of venous disease

Symptoms:
  • Pain / itching / aching / swelling of the affected leg
  • Discomfort after prolonged standing + relieved with leg elevation
  • Restless leg and leg crams (usually nocturnal)

Possible examination findings:
  • Varicose veins (defined by ≥3 mm dilated in upright position)
  • Brown-red hyperpigmentation (from haemosiderin deposition)
  • Venous eczema (red scaly and/or flaky skin)
  • Lipodermatosclerosis (painful, hardened, tight skin)
  • Atrophie blanche (star-shaped, white, depressed scars with surrounding pigmentation)
  • Venous ulcers (usually happens in severe untreated disease)
 

Site: gaiter area (ankle to mid-calf), most commonly the medial malleolus:
  • Painless, or mild pain relieved by elevation
  • Irregularly shaped
  • Shallow base
  • Presence of granulation tissue and exudate

 

Aarterial and neuropathic ulcers
 

Typical arterial ulcer features:
  • Very painful
  • Located at pressure points (e.g. heels, toes)
  • Regularly shaped with deep punched out appearance

Typical venous ulcer features:
  • Painless 
  • Located at pressure points (e.g. heels, toes)
  • Often associated with diabetic neuropathy or other neuropathies (e.g. B12 deficiency)

Varicose Veins Guidelines

Refer to secondary care (vascular service) to consider interventional treatment if any of the following:
  • Chronic venous insufficiency symptoms (e.g. pain, aching, discomfort, swelling, heaviness, itching)
  • Chronic venous insufficiency skin changes (e.g. pigmentation, eczema)
  • Superficial vein thrombosis (hard painful superficial vein)
  • Presence of venous leg ulcer (active / healed)
  • Bleeding varicose vein

If referral is not needed → manage in primary care

Offer ALL the following:
  • Lifestyle advise
    • If overweight / obese → weight loss
    • Engage in light to moderate physical activity
    • Avoid exacerbating factors (e.g. prolonged standing / sitting)
    • Elevate legs when possible
 
  • Compression stockings, only if arterial insufficiency is excluded by a normal ABPIAnkle-brachial pressure index
 

Varicose veins are common and physiological in pregnancy, they often improve after pregnancy

1st line: duplex ultrasound to confirm diagnosis and plan treatment.

Interventional treatment options:
  • Surgical ligation (tying off) and stripping (removal) of affected vein 
  • Endothermal ablation – sealing off affected veins with radiofreqeuncy or endovenous laser
  • Foam sclerotherapy - injection of an irritant foam into the vein causes an inflammatory response that closes the vein off
  • Cyanoacrylate glue bio-adhesive occlusion - closes the veins by adherence and fibrosis of the lumen

Leg Venous Ulcer Guidelines

All patients:
  • Wound management by district nurse / tissue viability nurse
    • Wash affected leg normally in tap water and dry carefully
    • Apply simple non-adherent dressings
 
  • High compression multicomponent bandaging, if arterial insufficiency is excluded by a normal ABPIAnkle-brachial pressure index
    • Offer the strongest compression that they can tolerate
    • Assess for skin complications within 24-48 hours of initiation
    • Replace every 3-6 months
 
  • Repeat Doppler ultrasound every 6-12 months

Consider pentoxifylline as an adjunct to aid ulcer healing

Also offer lifestyle advice:
  • If overweight / obese → weight loss
  • Engage in light to moderate physical activity
  • Avoid exacerbating factors (e.g. prolonged standing / sitting)
  • Elevate legs when possible

References

Author: Adams Lau
Reviewer:
Last edited: 28/07/25