Varicose veins are dilated superficial veins in the leg. They are caused by incompetent valves, commonly in the long and short saphenous veins and their branches, although varicosities may be secondary to deep venous disease. They are not to be confused with intra-dermal spider veins or thread veins which lie within the skin.
Asymptomatic or mild varicose veins present as a few isolated, raised palpable veins with no associated pain, discomfort or any skin changes. Moderate varicose veins present as local or generalised dilatation of subcutaneous veins with associated mild pain or discomfort and slight ankle swelling. Severe varicose veins may present with phlebitis, ulceration, haemorrhage, significant oedema or haemosiderin staining.
Most varicose veins respond to conservative management, i.e. exercise, weight loss and elevation of the leg two to three times daily. Varicose eczema, if severe or inflamed, can be treated effectively with topical steroids.
Interventional procedures such as surgical stripping or ligation, radio-frequency ablation, endoscopic procedures and sclerotherapy (e.g. ‘foaming’) can improve symptoms in the short term but are less effective in the longer term, and are associated with a significant recurrence rate.
Interventional procedures for mild and moderate varicose veins will not normally be commissioned by NHS Kernow.
Varicose vein treatment is commissioned where patients meet the criteria below, the referral letter and patient’s medical record need to clearly evidence how these criteria are met:
- Lower-limb skin marked eczema which has not responded to conservative measures
- Superficial vein thrombosis (characterised by the appearance of hard, painful veins) and suspected venous incompetence
- Recurrent or ascending superficial phlebitis (DVT risk may be as high as 10 to 20 per cent at presentation)
- A lower limb venous ulcer not healed within two weeks, with or without obvious varicose veins
- A healed venous leg ulcer
- Severe swelling or pitting oedema
- Symptomatic varicose veins in the presence of arterial insufficiency (absent pedal pulses)
- Incipient ulceration with erythema and skin induration
- Bleeding varicose veins
(Refer bleeding varicose veins to the vascular service via the on-call surgical team at RCHT)
Patients not suitable for referral to vascular surgical clinics for NHS treatment:
- Patients who do not fulfil the above criteria
- Patients whose concerns are cosmetic only
- Patients with pain or ache only, itch, mild swelling, minor changes of skin eczema and haemosiderosis
Further details of the Cornwall lower limb pathway for leg ulcer management are available here
Diabetic foot problems should be managed according to the pathway here
Where referral criteria are not met but it is felt a case represents an exceptional clinical need, referral should be made via the Individual Funding Request panel. Further details and the application form are available here
Date reviewed 12/02/2020
Next review 12/02/2021
Author Dr Joseph Rintoul, RMS Vascular Lead