Chronic venous insufficiency, particularly in ambulatory patients, manifests clinically in symptoms and sequelae of lower extremity hypertension due to reflux, with or without associated obstruction. This is a timely issue because it is increasingly evident that both medical practitioners and the public are seeing the link between chronic venous insufficiency and a group of symptoms, particularly leg ulcers. Until recently, this link has been entirely anecdotal and based upon an incomplete understanding of the pathophysiological processes involved. It is widely believed that the primary cause of varicose veins is a superficial venous reflux secondary to valvular incompetence, with an associated etiology of venous hypertension. Despite this cause and effect being documented in the early 1900s, it is only recently that medical research has provided the technology for diagnosis and treatment, and has also increasingly shown the importance of chronic venous insufficiency as the etiological factor of a number of symptoms and signs. This review will explore the link between chronic venous insufficiency and a number of features of lower limb skin damage, particularly the often misdiagnosed condition of venous eczema.
Causes of Varicose Veins
There are primary and secondary causes of venous insufficiency, which result in varicose veins. Primary venous insufficiency occurs when genetic weakness in the vein wall or valve occurs. This has a hereditary link and can increase with age. The exact cause is unclear, but it is thought that smoking and obesity can be contributing factors. Secondary venous insufficiency can be caused by anything that increases pressure in the abdomen, as this causes an increase in the pressure in the veins of the legs. An example of this is pregnancy, where there is both an increase in estrogen levels, which causes a relaxation of the vein walls, and an increase in blood volume, along with direct pressure from the uterus on the iliac veins. High pressure can cause those who have previously had good valve function to develop varicose veins.
Varicose vein is caused by increased pressure in the veins, leading to venous insufficiency. The calf muscle pump plays a crucial role in aiding the flow of venous blood back to the heart. Veins have a series of one-way bicuspid valves. In normal veins, the act of walking or the calf muscle contracting causes an increase in pressure on the veins. When this pressure exceeds the pressure below the valve, it opens, allowing blood to flow through. The valve then closes. If a valve becomes incompetent, it does not close properly, preventing the normal backflow of blood. This can cause a further increase in vein pressure and cause veins to become dilated and tortuous.
Symptoms and Complications
Untreated higher pressure in the leg veins can cause inflammation in the vein and skin, lipodermatosclerosis (inflammation and hardening of the subcutaneous fat), and corona phlebectatica (small clusters of visible veins near the ankle). These conditions are indicators of severe skin changes and an increased risk of venous ulceration. Inflammation in a vein, superficial thrombosis (clot), and bleeding from a varicose vein are acute complications that require medical treatment.
Varicose veins are often seen as a cosmetic problem, but left untreated, they can cause serious chronic health issues. Non-healing venous ulcers can have a major impact on a person’s quality of life, with pain, loss of mobility, and disability. The cause of the ulcer is long-term higher pressure in the leg veins, which damages the skin and makes it more prone to ulceration. Venous leg ulcers are a major cause of time off work and long-term sick leave.
Aching and discomfort in the legs, easy leg fatigue, and leg heaviness are early symptoms, which are usually worse at the end of the day, heat, and standing. Symptoms include ankle swelling at nighttime, leg cramps, and restless legs. People with these symptoms are at risk of skin damage: brown discoloration near the ankle, atrophy of the skin, and in severe cases, an ulcer may develop.
Treatment Options for Varicose Veins
For patients without skin changes or significant symptoms from their varicose veins, conservative treatment is a reasonable option. Unfortunately, conservative therapy can only prevent worsening of varicose veins and is ineffective in their improvement or resolution. Elastic compression stockings are a cheap and safe modality that help symptoms resulting from large veins. Their use does carry the inconvenience of having to wear tight-fitting stockings throughout the day, and they do nothing to help appearance. Lifestyle modifications involving weight loss and regular exercise are both beneficial for overall patient health and cardiovascular fitness but are of limited effectiveness for improvement in varicose vein symptoms.
In the past, treatment of varicose veins frequently involved daily dietary intake of fiber and use of laxatives to treat constipation in an effort to reduce abdominal straining. Avoidance of high heeled shoes in women and leg-crossing in men were thought to be helpful. Elastic compression stockings have been shown to be of some benefit in preventing worsening of varicose veins but provide no means for improvement in the appearance or symptoms associated with varicose veins. When used in the setting of venous ulceration, compression bandages are helpful in wound healing. Intermittent pneumatic compression devices have also been used as a means of compression therapy. Both modalities are cumbersome and their use is limited by poor patient compliance. Unfortunately, most modalities of conservative management are simply ineffective in the treatment of varicose veins and venous insufficiency.
