Are varicose veins just a pesky eyesore or should pharmacists intervene, asks Rod Tucker
Varicose veins are a common problem affecting up to three in 10 adults, although the condition is more prevalent in women (up to 33%) than men (up to 20%).
Typically, they present as swollen veins on the back of the calf or sometimes on the inside of the leg, but they can also occur in the pelvic region, rectum or vagina. The veins have a bulging, lumpy or twisted appearance and are usually purple or dark blue.
In many instances, varicose veins are simply a cosmetic nuisance that do not cause any problems. However, patients can experience varying degrees of pain, soreness, burning, aching, throbbing, muscle fatigue, restless legs and cramping, especially at night. These symptoms are often worse during the warmer weather and more noticeable after standing for long periods of time.
In order to understand how varicose veins form, it is useful to have a basic understanding of the venous system in the legs. There are essentially three types of veins in the lower limbs:
The deep veins are located within the muscles whereas the superficial veins are closest to the skin and collect blood from capillaries and the surrounding subcutaneous tissue. The blood from the superficial veins drain into the perforator veins and ultimately the deep veins. Since the role of veins is to return blood to the heart, the inner cavity of veins contains a series of one-way valves that prevent backflow of blood.
The precise cause of varicose veins remains uncertain but for some reason, failure of a single valve leads to a high-pressure leak between a deep and superficial vein. The increased pressure in the superficial vein causes dilatation of the vessel wall which prevents the valve from closing properly, allowing blood to flow in either direction.
During subsequent contractions of the calf muscle, the failure of the one-way valve creates a higher than normal pressure that easily spreads back throughout the superficial venous network causing dilation of the walls and failure of a larger number of valves.
The development of varicose veins is thus a gradual process such that over time, more of the superficial veins acquire the typical dilated and tortuous appearance.
Potential risk factors
Studies of twins have confirmed that genetic factors play an important role in the development of varicose veins. A positive family history is the most common risk factor, although the particular genes involved have not been identified. Inheritable factors are more of a problem in females than males.
2. Prolonged standing/sitting
Standing for long periods of time – as well as prolonged sitting – will increase the hydrostatic pressure of blood due to gravity and cause distension of superficial veins. This leads to both a pooling of blood and the inability of valves to properly close.
Several studies have confirmed that among workers whose job involves either prolonged standing or sitting, there is an increased incidence of varicose veins. It is more problematic for women, as vein walls become distensible due to the effects of progesterone each month. One study found that prolonged standing increased the risk of both varicose veins and nocturnal night cramps.
It has been estimated that up to 40% of pregnant women suffer with varicose veins. The hormonal fluctuations during pregnancy lead to a relaxation of vein walls, increasing their distensibility and reducing the ability of valves to close properly. Moreover, the increased circulating blood volume and an enlarging uterus serve to create a higher pressure in the pelvic veins, which further increases the risk of varicose veins in the lower legs. Varicose veins can also develop during the peri-menopause and post-menopausal phase of a woman’s life.
4. Other factors
Obesity increases the pressure on veins and ultimately the valves, making them more prone to leaking. In addition, with advancing age, the elasticity of veins reduces and the smooth muscle starts to degenerate which makes the veins more susceptible to dilatation.
There is some weak evidence that smoking may also be a risk factor and one recent study has identified that increased height is associated with an increased susceptibility to varicose veins.
Bleeding of varicose veins can occur after trauma to the vein and while this is an uncommon problem, it is more likely in older people who have fragile skin. Though the bleeding is not life-threatening, it can seem quite dramatic as veins contain a large amount of blood.
A more common problem is superficial thrombophlebitis (blood clots), which occur in up to 80% of cases when sluggish blood flow through the vessels causes trauma to a varicose vein. A superficial thrombophlebitis presents with a painful hard lump beneath the skin with associated inflammation. Fortunately, superficial blood clots do not travel through the venous system and the condition is not serious. The clot will normally clear in a few weeks and most patients with the condition are otherwise well.
In the long term, varicose veins can lead to chronic venous insufficiency, which arises due to increased blood pressure in the superficial and/or deep veins. This produces both oedema and skin changes. The oedema causes fluid leakage out of the veins and into the surrounding tissue and triggers an inflammatory response. Over time, the skin becomes hardened, pruritic and discoloured, often becoming a ‘rusty’ brown colour. This form of eczema is variously referred to as varicose, gravitational or venous eczema and can ultimately lead to the formulation of a venous leg ulcer.
See below for when to refer patients to another healthcare professional.
Management of varicose veins
Many patients will probably seek advice on treatment for varicose veins because of the unsightly nature of the condition. However, there is little evidence that any intervention can prevent the appearance or development of varicose veins.
Though most are asymptomatic, pharmacists should establish whether patients experience any symptoms. If the skin is pruritic, then simple emollients can be used, especially if the skin is dry or flaky.
It is worth advising patients to lose weight if appropriate and to exercise regularly as this can help improve the circulation. Patients should be advised to avoid activities such as prolonged standing or sitting, which can worsen varicose veins and to elevate their feet above the level of the hips wherever possible as this will reduce blood pooling.
Although compression hosiery is often used for people with varicose veins, NICE could not find convincing evidence that this is an effective treatment option. NICE guidance on the management of varicose veins published in 2013 suggests that stockings may be used as an alternative if secondary care treatments (see below) are either unsuitable or not effective.
If compression stockings are to be used, then below-knee class one or two are the most appropriate and should ideally be put on first thing in the morning before getting out of bed and removed when going to bed.
It is possible that compression stockings used by pregnant women may offer symptomatic relief but do not prevent the emergence of varicose veins or the subsequent development of complications. However, compression stockings reduce the risk of reoccurrence of leg ulcers that are a complication of varicose veins.
Referral to a GP
The NICE guidance says pharmacists should promptly refer patients with any of the below symptoms to their GP:
- Bleeding varicose veins
- Recurrent varicose veins that are symptomatic (eg associated with pain, swelling, itching) or with skin pigmentation due to chronic venous insufficiency
- Superficial vein thrombosis in which there are hard, painful veins
- A venous leg ulcer (a break in the skin below the knee) that has not healed within two weeks.
If pharmacists encounter patients with any of the above symptoms, they should be promptly referred to the GP.
Secondary care treatments
NICE recommended that patients with confirmed varicose veins and truncal reflux that is causing troublesome symptoms such as bleeding should be referred to a vascular specialist. Treatments include endothermal ablation, in which high-frequency radio waves or lasers are used to seal the affected veins. If this approach is unsuccessful, then ultrasound-guided foam sclerotherapy can be used, which involves injection of a foam into the veins which scars the vein and seals it. Patients who do not respond to either treatment can be managed surgically by removal of the affected vein.
Rod Tucker is a community pharmacist