Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Recognise venous hypertension complications, refer according to NICE criteria and sequence duplex-guided intervention correctly.
Superficial or deep venous reflux and outflow obstruction raise ambulatory venous pressure. The clinical spectrum runs from telangiectasia and varicose veins through oedema, eczema/pigmentation, lipodermatosclerosis and healed or active ulceration.
Symptoms include aching, heaviness, itching, throbbing and swelling that worsen with standing. Severity of visible veins does not reliably predict symptoms or complications, so referral is based on bleeding, symptoms and skin/ulcer consequences rather than appearance alone.
Intervention treats the reflux source. Adjuncts—walking/calf-pump exercise, weight management, elevation, skin care and compression when appropriate—support symptom control but do not replace a NICE-indicated vascular assessment.
Vein-wall dilatation and valve incompetence permit retrograde flow, producing tortuous superficial veins. Age, family tendency, pregnancy and prolonged standing commonly increase susceptibility or symptoms.
Previous DVT may leave valve destruction and residual outflow obstruction. The resulting deep venous hypertension can drive oedema, skin change and secondary superficial reflux.
Obesity, pregnancy, immobility and reduced ankle movement increase hydrostatic load or weaken calf-muscle emptying. These factors aggravate venous hypertension even when they are not the sole cause.
Incompetent valves allow blood to fall back during standing, while deep obstruction impedes return. Either mechanism raises the volume and pressure carried by lower-limb veins.
The calf pump no longer lowers venous pressure effectively during walking. Sustained pressure dilates superficial tributaries and transfers stress to capillaries and surrounding tissue.
Increased capillary hydrostatic pressure drives fluid and red-cell products into the interstitium. Persistent leucocyte activation and inflammation cause itching, eczema and haemosiderin pigmentation.
Chronic inflammation remodels skin and subcutaneous fat, producing induration and lipodermatosclerosis. Fragile, poorly nourished gaiter skin can then break down into a recurrent venous ulcer.
Aching, heaviness, swelling, itching or throbbing attributed to visible primary or recurrent varices; meets NICE vascular-referral criteria.
Dependent pitting ankle/lower-leg swelling, often worse later in the day and improved by elevation; bilateral causes and cardiac/renal disease remain alternatives.
Gaiter hyperpigmentation, stasis eczema, induration and lipodermatosclerosis indicate chronic venous hypertension and warrant vascular referral.
An active ulcer below the knee that has not healed within 2 weeks, or a healed venous ulcer, meets referral criteria.
External bleeding can be brisk from a small skin breach, especially with dependency; elevate, apply firm direct pressure and refer immediately.
Sudden unilateral swelling, deep pain and tenderness require acute DVT assessment. Chronic venous disease more often causes longstanding dependent symptoms, pigmentation and visible varices, although both can coexist.
Lymphatic swelling often involves the dorsum of the foot and becomes firm or non-pitting, with skin thickening. Varicosities, gaiter pigmentation and reflux on duplex favour venous disease.
Systemic fluid retention is commonly bilateral and accompanied by jugular venous, urinary or hepatic abnormalities. Isolated gaiter changes and mapped reflux support a predominantly local venous cause.
Fever, pain and rapidly spreading unilateral warmth favour infection. Chronic bilateral itch, scale, pigmentation and oedema are more consistent with stasis eczema than recurrent cellulitis.
Arterial ulcers are often distal, painful and punched out with a cool foot and reduced pulses. Venous ulcers favour the gaiter region with oedema and preserved warmth.
A tender cord suggests SVT; sudden diffuse unilateral swelling, deep pain or PE symptoms require urgent DVT/PE assessment.
Sustained microvascular pressure and inflammation cause gaiter skin breakdown. Ulcers can be painful, exudative and recurrent, impairing mobility and quality of life.
Chronic oedema and red-cell extravasation produce eczema, pigmentation and subcutaneous fibrosis. Skin becomes inflamed and fragile, increasing ulcer risk and sometimes mimicking cellulitis.
Thrombosis within a varicose tributary causes a tender, erythematous cord. Extension towards the deep system or accompanying diffuse swelling requires assessment for venous thromboembolism.
Thin skin over a pressurised superficial vein can rupture after trivial trauma or spontaneously. Bleeding may be brisk while the limb is dependent and needs elevation, firm direct pressure, immediate medical assessment and vascular referral.
Excoriated eczema or an open ulcer can permit bacterial infection. New pain, warmth, rapid erythematous spread or systemic illness distinguishes infection from stable inflammatory skin change.
Pain, swelling, skin change, SVT and ulcer history are clinical indications even when the visible veins seem modest.
Venous pressure falls rapidly with elevation and direct pressure, but definitive reflux treatment is still needed.
Endothermal ablation precedes foam, which precedes surgery when each earlier option is unsuitable.
It is core treatment for venous ulceration after arterial assessment, but NICE does not use it as definitive varicose-vein treatment when intervention is suitable.
Chronic bilateral itch, scale and pigmentation favour stasis dermatitis; fever, pain and rapid unilateral spread favour infection.
Applying a tourniquet proximal to a bleeding varicosity instead of elevation and direct pressure.
Offering lifelong hosiery without vascular referral to an otherwise suitable patient with symptomatic truncal reflux.
Treating stasis eczema repeatedly with antibiotics as cellulitis.
Starting strong compression without assessing arterial perfusion in a patient with ulceration or weak pulses.
Performing routine varicose-vein intervention during pregnancy.
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Duplex confirms symptomatic great saphenous truncal reflux. Which treatment sequence follows NICE guidance?
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes