Varicose veins
Varicose veins are swollen, twisted veins that show under the skin, usually on the calves and thighs.
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Medicines commonly prescribed for Varicose veins
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: Solution for injection, 2 mgActive substance: sodium tetradecyl sulfateManufacturer: Std Pharmaceutical (Ireland) LimitedPrescription requiredDosage form: INJECTABLE, 3%Active substance: sodium tetradecyl sulfateManufacturer: Std Pharmaceutical (Ireland) LimitedPrescription requiredDosage form: INJECTABLE, 0.5%Active substance: sodium tetradecyl sulfateManufacturer: Std Pharmaceutical (Ireland) LimitedPrescription required
Varicose veins are swollen, twisted veins that show under the skin, usually on the calves and thighs. They are very common and in themselves they are almost never dangerous: a great many people live with them for decades and need no treatment at all. But there is a second side to them that gets talked about less. Some veins eventually start to cause real trouble: the leg feels heavy and swells by the evening, the skin above the ankle darkens and hardens, itching appears, and sometimes a sore that will not close. That is no longer a cosmetic matter, and watching instead of treating gets expensive. The point of this page is to help tell the two situations apart, and to show what is offered nowadays instead of major surgery.
What they look like and how they feel
Varicose veins are usually easy to see and easy to feel: they stand out under the skin as soft, winding cords, bluish or skin-coloured, and they are at their most obvious when a person is standing. Lie down and raise the leg and they empty; that is what a vein normally does, not a sign that the problem has gone.
Symptoms do not affect everybody, and they match the size of the veins poorly: a thick, ropey vein may cause no trouble at all, while barely visible ones can make a leg feel genuinely heavy. The usual picture is this:
- heaviness, a bursting feeling and a dull ache in the calf that builds up as the day goes on;
- swelling of the ankle and foot: by the evening the sock leaves a mark, and by morning the leg is back to normal;
- burning and itching along the line of the vein;
- cramp in the calves at night;
- relief from lying with the legs raised or from walking, and worsening after long spells of standing, in hot weather or after a hot bath.
Thread veins and spider veins — fine red, blue or purple vessels sitting in the skin itself — are not varicose veins: they do not bulge, they do not make a leg heavy, and they are treated for appearance only. That said, sometimes thread veins are all that shows on the surface while a vein with failed valves already lies underneath, so when they come with swelling and heaviness they should not be dismissed.
Why veins become varicose
Blood travels up the veins of the leg against gravity. Two things hold it there: the valves inside the vein, thin flaps that stop blood falling back down, and the calf muscles, which squeeze the deep veins with every step and push blood on towards the heart. Once the valves stop meeting, some of the blood drops back. Pressure inside the vein rises, the wall stretches, the flaps are pulled further apart, and the cycle feeds itself. The vein also lengthens and, with nowhere to go, it buckles into loops — hence the knotted appearance.
All of this happens in the superficial veins, the ones lying just below the skin. The main return route is through the deep veins inside the muscles, and in varicose veins those usually work perfectly well. Closing or removing a superficial vein therefore does not deprive the leg of a channel it needs: the blood simply takes the correct route.
It is more likely if a parent had varicose veins, with age, in pregnancy, with excess weight, in work that involves hours of standing or sitting still, and after a deep vein thrombosis. Women are diagnosed more often. Veins that appear during pregnancy frequently shrink or disappear in the first months after the birth, so treatment is not usually undertaken before then; compression stockings are used in the meantime.
When it is cosmetic and when it is a disease
Varicose veins with no symptoms and no skin changes are something a person can live with quite happily and leave alone. Having them dealt with because of how they look is a perfectly reasonable choice, but it is a choice rather than a medical necessity.
Signs that the pressure in the veins is already damaging the tissues of the lower leg are a different matter. Here waiting works against you: skin changes take years to develop and reverse badly. It is worth showing the leg to a doctor and discussing treatment rather than monitoring if any one of these is present:
- swelling of the lower leg and ankle that no longer settles completely overnight;
- heaviness and pain by the evening that force you to change how you spend the day;
- a change in skin colour above the ankle: rusty brown patches on pale skin, and on darker skin areas that are darker than the surrounding skin, shiny or greyish. This is iron from blood that has leaked through the vessel wall, and it does not fade on its own;
- hardening of the skin above the ankle, where the area becomes firm and tight, as if belted, and the calf above it looks fuller;
- itchy, flaking eczema over the veins;
- an ulcer on the lower leg, open or healed: an ulcer that healed years ago is as much an indication as an open one, because without treating the veins it comes back;
- even a single episode of bleeding from a varicose vein.
This page is about the veins themselves. For the skin of the lower leg — why it darkens, itches and flakes, what to put on it and how to stop it reaching the ulcer stage — see the page on varicose eczema. The cause is shared, but the questions are different.
What helps day to day
A caveat first, to save disappointment: none of the following removes veins that are already dilated or restores the valves. These measures reduce symptoms, hold back the swelling and protect the skin, which is a good deal, but they are not treatment of the veins.
- Walking. Not the general advice about exercise but a specific mechanism: with every step the calf muscle works as a pump. Half an hour of walking a day does more for the legs than any cream.
- Breaks in standing and sitting work. Every half hour, rise onto your toes ten or fifteen times, circle the ankles, take a few steps: it is staying still that does the harm, not the position itself.
- Legs up, and weight. Twenty to thirty minutes lying with the feet above the level of the heart is the quickest way to bring down evening swelling. Extra weight means extra pressure in the veins of the pelvis and legs.
- Skin care and caution. Dry skin on the lower leg is moisturised daily: cracked skin gets scratched, and such a spot easily turns into a sore that then heals badly. The thin skin over a large vein splits on the corner of a piece of furniture or a step, and that is a common cause of bleeding.
Products from the pharmacy have a modest place here. Venotonic tablets may take the edge off the heaviness and swelling, a doctor decides on them, but they do nothing to the veins themselves; creams and gels give a pleasant cooling sensation and little more.
Compression stockings: what they do and what they do not do
Compression stockings squeeze the leg from outside, more firmly at the ankle and less further up. They support stretched veins, help the muscle pump and clear the swelling. Heaviness and tiredness at the end of the day ease off, and for many people that is enough to live with varicose veins without any procedure at all.
But this has to be said plainly: a stocking relieves symptoms and does not get rid of veins. The dilated vein underneath stays dilated, the valves do not start closing again, and the moment the stocking comes off everything returns. That is not an argument against compression; it is an argument against spending years in a stocking instead of having the conversation about treatment when there are already reasons to treat.
The compression class and the size are chosen by a doctor, who first has to be sure that the arterial blood supply to the leg is intact — by feeling the pulse in the foot and, if there is any doubt, measuring the ankle-brachial pressure index, comparing the pressure at the ankle with the pressure at the arm. If the arteries are narrowed, the leg must not be compressed. Stockings go on in the morning, before the leg swells, and come off at night. If one rolls down into a band, cuts in or rubs, that is a reason to change the size rather than to put up with it: the rolled band acts as a tourniquet. Stretched fabric no longer compresses, so stockings are replaced every few months.
How they are assessed and treated today
There is usually one investigation and it is enough: a duplex ultrasound scan of the veins. It shows which veins fail to hold blood, exactly where the valves are leaking and whether the deep veins are sound. Treatment is not planned without it — removing a visible vein without knowing where the reflux into it is coming from is the fastest route to getting it back.
Major surgery has stopped being the main option. These days the vein is usually not taken out but closed from the inside through a puncture, under local anaesthetic, and the person goes home the same day.
- Endothermal ablation, by laser or radiofrequency. A fine instrument is passed into the vein through the puncture and heats it from within; the walls stick together, the vein stops carrying blood and is gradually replaced by a strand of fibrous tissue. It is the first-choice method for the large trunk veins today.
- Sclerotherapy. A substance, usually as a foam, is injected into the vein and makes it stick shut. It suits smaller veins, tributaries and thread veins, and normally takes several sessions.
- Glue closure and mechanochemical ablation. Options without heat, and therefore without the need to anaesthetise the whole length of the vein; they are used when the thermal methods do not fit.
- Surgical removal of the vein. The trunk is tied off and pulled out, and tributaries are taken through tiny incisions. It is still needed with certain anatomy and with very bulky veins, and is done under general or spinal anaesthetic.
Common to all of them: compression stockings for a few days afterwards, with bruising and a pulling sensation along the vein for a week or two. And one thing worth knowing in advance — treatment removes the veins that were treated but does not cancel the underlying tendency. After some years a proportion of people find new dilated veins, and that does not mean the procedure was done badly.
When to be seen urgently
Emergencies from varicose veins are uncommon, but they exist and are worth recognising.
A painful, hot cord along the line of a vein. The vein turns hard, like a length of rope, and the skin over it reddens, feels hot and hurts to touch. That is superficial vein thrombosis, or thrombophlebitis. It is not usually dangerous in itself, but it needs examination and an ultrasound scan within a few days: the point is to find out how far up the clot reaches and whether it has extended into the deep veins. Do not apply heat to the area, rub it or massage it.
One whole leg swollen, with pain in the calf. Swelling of one leg only, pain or tightness in the calf and skin that is warmer than usual may mean a deep vein thrombosis. See a doctor the same day, not tomorrow. If breathlessness, chest pain on breathing in, a racing heartbeat or blood on coughing are added to that, call an ambulance: this is how a pulmonary embolism presents. Spain, Italy, Portugal, Poland and Ukraine share the single emergency number 112.
Bleeding from a varicose vein. The thin skin over a vein sometimes splits at the slightest knock and, because the pressure inside is high, the blood comes out in a jet, which is frightening to watch. What to do straight away: lie down, raise the leg as high as you can and press hard on the spot with a clean cloth; keep pressing for ten to fifteen minutes without lifting your hand to look. In that position the bleeding almost always stops. Then put on a firm bandage, keep the leg raised and see a doctor even if the bleeding has settled. If you cannot stop it, call an ambulance. Bleeding is a direct indication to treat the veins: once it has happened, it happens again.
Online consultation
With varicose veins, an online appointment is most useful for making sense of the situation. The doctor will ask about the symptoms and about how the leg behaves by evening and after a night's rest, will look at photographs of the leg taken in good light standing and lying down, and will help with the main question: is this cosmetic and safe to live with, or are these already the changes that call for a vascular surgeon.
It is also the place to work out whether a duplex scan is needed and what it will show; how laser, radiofrequency and sclerotherapy differ and why the choice between them follows the scan rather than the price list; how to choose compression stockings and how to wear them; what to do about the legs in a standing job and during pregnancy. It often helps to read through an ultrasound report you already have and work out what it actually says.
The limits are straightforward. A diagnosis is not made from a photograph: the state of the valves shows only on ultrasound. Compression is not prescribed without checking the arterial supply. And if one leg has swollen and the calf hurts, if a hot painful cord has appeared along a vein, or there has been an episode of bleeding, what is needed is not a conversation on a screen but a doctor in person, today.
This material is for information only and does not replace medical advice.
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Discuss your symptoms and possible next steps for Varicose veins with a doctor online.
