Author: Ramez Barsoum, Resident Medical Officer, Princess Alexandra Hospital, Brisbane, QLD, Australia. DermNet NZ Editor in Chief: Adjunct A/Prof Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. April 2019.
Varicose veins are engorged, tortuous, green, blue, or purple veins that are often found on the lower legs and feet.
Varicose veins are also called varices or varicosities.
Approximately one-third of men and women aged 18–64 years have varicose veins . They are more common in women and those with a family history of venous disease.
In normal leg veins, one-way valves direct the flow of venous blood from superficial venules to larger superficial veins, then to the deep veins, and eventually to the heart. Muscle contractions create a pumping action to help the flow of blood to the heart (the venous return).
Patients with varicose veins present because they are unsightly and because of a feeling of discomfort, heaviness, itching, or a dull ache. Patients can also present with complications such as bleeding, ulceration, and thrombophlebitis.
Superficial veins are prone to trauma and can bleed, which can be potentially life-threatening [6,7].
The increased pressure in varicose veins allows growth factors and circulating pro-inflammatory molecules to leak into the extravascular space, which leads to localised inflammation and the formation of a chronic venous leg ulcer.
Phlebitis is inflammation of the veins with erythema and painful induration of the affected veins. It is often associated with thrombosis (thrombophlebitis) . Thrombosis arises because of sluggish circulation of blood in the vein combined with a hypercoagulable state and may be superficial (superficial thrombophlebitis) or deep (deep vein thrombosis) .
Venous stasis dermatitis is associated with increased venous pressure and pooling of inflammatory molecules. Patients present with brown discolouration, pruritus, and discoid or circumferential, acute or chronic eczema on the distal lower limbs .
Varicose veins are diagnosed clinically. A physical examination should include the entire venous system and is usually conducted with the patient lying down and standing up.
The National Institute for Health and Care Excellence uses the Clinical Etiological Anatomical Pathophysiological (CEAP) classification of varicose veins:
Duplex Doppler ultrasound assessment should be performed to determine the extent of disease and the level of truncal reflux  and to plan treatment options.
Varicose veins are larger than telangiectasia (small red 'thread' veins, < 1 mm in diameter) and venulectasia (blue reticular vessels, 1–3 mm in diameter). These are not detected on duplex ultrasound.
Weight loss (if overweight) and moderate physical activity should be encouraged in patients with varicose veins to reduce the risk of complications. Compression hosiery should be used to relieve discomfort and swelling, and especially when travelling.
Treatment options for varicose veins are available from a vascular service.
Endovenous thermal ablation using a laser or radiofrequency device causes an irreversible thermal injury in the vein wall, which leads to scarring and absorption of the tissue over several months. The success rate for both different methods of ablation is 95% [9,10].
Sclerotherapy involves the injection of a sclerosant under ultrasound guidance to cause inflammation of the vessels of the wall and eventual collapse of the varicose network. Smaller surface veins can be injected by microsclerotherapy, involving smaller gauge needles with smaller amounts of sclerosant .
Endovenous adhesive ablation or 'vein glue' technique involves the injection of a medical grade adhesive cyanoacrylate glue through a catheter. Long term safety and efficacy data are lacking .
ClariVein is a rotating occlusion catheter that mechanically agitates the vein lining while also spraying a liquid sclerosant. It induces more endothelial damage but lacks long term data .
High ligation, vein stripping and avulsion are less often used to treat varicose veins than in the past due to postoperative morbidity, recurrence rates, and the risks associated with anaesthesia and hospitalisation .
Telangiectasia and venulectasia can be treated with long wavelength vascular lasers, but these are unsuitable for larger varicose veins .
Whichever treatment option is used, varicose veins may recur and can be treated again..
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