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Varicose veins
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Exam Tips
- In OSCEs, inspect legs both standing and lying: varicose veins are >=3 mm in the upright position; smaller intradermal veins suggest reticular/telangiectatic disease.
- Key referral triggers: symptomatic primary/recurrent varicose veins, skin changes of chronic venous insufficiency, superficial vein thrombosis with suspected venous incompetence, and active/healed venous ulcer.
- Bleeding varicose veins are a vascular emergency: apply direct pressure, elevate limb, and arrange urgent specialist assessment.
- Always mention ABPI/arterial assessment before compression to avoid harm in significant peripheral arterial disease.
- For anatomy recall and viva explanation, see figure of superficial vs deep venous systems and perforators in your vascular surgery text.
Definition
Varicose veins are permanently dilated, tortuous superficial veins of the lower limb (typically at least 3 mm in diameter when standing) that reflect superficial venous reflux and chronic venous insufficiency. They are often a cosmetic concern but can also cause leg symptoms and, in a subset of patients, progress to skin damage, thrombosis, bleeding, or venous ulceration.
Pathophysiology
Normal lower-limb venous return depends on one-way valves directing blood from superficial veins into perforators and then the deep venous system. In varicose veins, valve incompetence causes retrograde flow (reflux), venous hypertension, and distal pooling; superficial veins, lacking the structural support of deep veins within fascia, progressively dilate and become tortuous. Vein wall weakness/degeneration and, in some patients, coexistent deep venous incompetence amplify pressure load and disease progression.
Risk Factors
- Increasing age
- Family history (strong hereditary contribution)
- Female sex
- Pregnancy (risk rises with parity)
- Overweight/obesity
- Prolonged standing or prolonged sitting
- Low physical function/inactivity
- Previous deep vein thrombosis causing secondary valvular damage
Clinical Features
Symptoms
- Visible prominent leg veins with cosmetic concern
- Aching or heaviness, worse after prolonged standing
- Leg discomfort improved by elevation
- Itching over affected veins
- Leg swelling (often dependent)
- Nocturnal cramps or restless legs
Signs
- Dilated tortuous superficial veins (>=3 mm in upright position)
- Tender, cord-like hard vein suggesting superficial vein thrombosis
- Venous skin changes: hyperpigmentation, venous eczema, lipodermatosclerosis, atrophie blanche
- Active or healed venous ulcer in gaiter area
- Bleeding point over a varix (often over bony prominence)
- Unilateral marked varicosities/swelling should prompt assessment for pelvic or abdominal mass
Investigations
Clinical examination (standing and supine):Confirms distribution/size of varicosities and identifies skin changes, thrombophlebitis, ulceration, or bleeding complications
Duplex venous ultrasound (vascular service):Demonstrates superficial venous reflux, maps incompetent segments/junctions, and helps exclude deep venous obstruction/DVT before intervention
Ankle-brachial pressure index (ABPI) before compression:Used to exclude significant arterial insufficiency; low ABPI suggests compression may be unsafe or needs specialist supervision
Targeted tests if atypical/red flags:If unilateral edema or systemic alarm features are present, investigate for alternative causes (e. g, pelvic/abdominal pathology, DVT)
Management
Lifestyle Modifications
- Explain condition and natural history; provide written information and safety-netting
- Weight reduction if overweight
- Regular light-moderate exercise (e. g, walking, calf-muscle activation)
- Avoid prolonged standing/sitting where possible
- Leg elevation when resting
- Use compression hosiery if intervention not indicated/while awaiting treatment, after arterial insufficiency is excluded
- If active bleeding from a varix: immediate first aid (direct pressure, leg elevation) and urgent same-day vascular admission/referral
Pharmacological Treatment
Analgesia for symptomatic discomfort (adjunct, not disease-modifying)
- Paracetamol 1 g orally every 4-6 hours when required (max 4 g/day)
- Ibuprofen 400 mg orally up to three times daily with food (use lowest effective dose; max 1.2 g/day OTC, up to 2.4 g/day only on prescription)
No routine drug reverses venous reflux. Avoid/limit NSAIDs in CKD, peptic ulcer disease, heart failure, anticoagulant use, or late pregnancy; consider gastroprotection where GI risk is high.
If venous eczema complicates varicose disease
- Emollient (e. g, white soft paraffin/liquid paraffin preparation) applied liberally several times daily
- Hydrocortisone 1% cream/ointment thinly once or twice daily for mild flares (short courses)
Treat associated skin inflammation; avoid prolonged unsupervised topical steroid use due to skin atrophy risk.
Surgical / Interventional
- Endothermal ablation (first-line interventional option when suitable anatomy)
- Ultrasound-guided foam sclerotherapy (if endothermal ablation unsuitable)
- Surgical ligation/stripping or phlebectomy (if minimally invasive options unsuitable)
- Urgent vascular management for recurrent or uncontrolled variceal bleeding
Complications
- Bleeding from eroded varicosities
- Superficial vein thrombosis
- Deep vein thrombosis
- Chronic skin changes (hyperpigmentation, venous eczema, lipodermatosclerosis, atrophie blanche)
- Venous leg ulceration
- Reduced quality of life and psychological distress/depressive symptoms
Prognosis
Disease can progress over time if untreated, with increasing extent of varicosities and risk of skin damage or ulceration. After appropriate intervention, most patients achieve good symptom relief, but recurrence/new varicosities are common over the long term.
Sources & References
🏥BMJ Best Practice(1)
💊BNF Drug References(1)
- Sodium tetradecyl sulfate[management.pharmacological]
✅NICE Guidelines(1)
- Varicose veins[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 535)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 535, 536)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 93, 94)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 92, 93)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 368)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 194)[context]
- Netter F. Netter Atlas of Human Anatomy. A Systems Approach 8ed 2022.pdf(pp. 2295, 2296)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2296, 2297)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2272, 2273)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 173)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 389, 390)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 722)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 672, 673)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 878)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 895)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 925, 926)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 923, 924)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 936)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 845)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 920, 921)[context]