Seriousness of varicose veins underappreciated, expert says

Key Points

"The burden of venous disease is very underappreciated - both by patients and practitioners," says Danielle K. Moul, M.D., a dermatologist in private practice at West Dermatology, in Rancho Santa Margarita, where she also directs the practice's vein clinic.

According to Dr. Moul, about 25 percent of the population has lower extremity varicose veins. (Rabe E, Pannier-Fischer F, Bromen K, et al. Phlebologie. 2003;32:1-14). Often, when she counsels patients presenting with symptoms of venous insufficiency, "They don't appreciate that leg heaviness, swollen legs at the end of the day, aching legs, restless legs and night cramps can be associated with venous disease.

However, she emphasizes that incompetent veins put people at risk of deep vein thrombosis, commonly referred to as blood clots.

"If left untreated long-term," she says, "people with more severe disease can develop non-healing skin ulcers. I don't believe the significance of deep vein thrombosis or skin ulcer is completely recognized by patients, and you know I don't believe that the medical community is fully aware of the breadth of minimally invasive treatments available for patients."

Diagnosis and treatment

When a patient presents with varicose veins, Dr. Moul says she performs a complete examination, including a comprehensive review of the patient's medical history and a complete ultrasound exam of the bilateral lower extremities evaluating the deep and superficial vascular systems of both legs.

As part of the examination, she says that using the CEAP classification (Clinical severity, Etiology, Anatomy, Pathophysiology) helps to assess the severity of a patient's problem both at presentation and over time.

The six grades of clinical severity range from no disease (C0) to disease levels characterized by healed (C5) and open (C6) ulcers. Although a patient with advanced disease can shift from C6 to C5 if an ulcer heals (and vice versa), she says that most cases of venous disease do not rapidly progress in severity.

Patients without arterial compromise begin with conservative therapy, which includes compression stockings, leg elevation and exercise such as walking, Dr. Moul says. Regarding compression stockings, she says, "Typically, I recommend 30 mm to 40 mm Hg grade because this will provide better compression than 20 mm to 30 mm Hg grade.

"Patients complete a two- to three-month trial of conservative therapy and are re-evaluated," she says. "If their symptoms persist, I recommend a treatment algorithm based upon their initial ultrasound findings."

Although insurance companies require documentation that patients have failed conservative therapy before approving any therapeutic procedures, Dr. Moul says, "The reality is that if the patient's venous valves are incompetent, their disease is not going to get better on its own. Patients may have some improvement of their symptoms, but their disease is still present."