Chronic venous disease (CVD) encompasses a broad spectrum of clinical presentations that range from the asymptomatic to advanced presentations, the most serious being venous ulcers. The most frequent signs and symptoms of CVD are varicose veins and skin changes. Skin changes may present as an early sign of CVD and in some cases may become the most troublesome aspect of the disease. The addition of skin changes to visible varicose veins is a common endpoint in the progression of CVD. It is therefore imperative to have an understanding of the nature of skin changes associated with venous disease.
Understanding Varicose Veins
Varicose veins are enlarged, twisted, ropelike veins that are swollen and raised above the surface of the skin. They can be flesh colored, dark purple or blue and usually are found on the back of the calves, or on the inside of the leg. They can cause heavy ache especially after prolonged standing and leg edema. People who are obese, pregnant, or who have a family history of varicose veins are more likely to develop the condition. Varicose vein do affect more females than males. This is due to the fact that female hormones will relax the vein walls. Hormone replacement therapy and birth control pills can also increase the risk of developing varicose veins, for the same reason. Other factors which can exacerbate the condition are leg injury and prolonged standing. The most common cause of varicose veins is venous reflux, which is a condition that is signified by enlarged, weakened, and poorly functioning vein walls and valves. Normally, one-way valves in the veins keep blood from flowing backwards. When the walls or the valves weaken, the blood will flow back and pool in the vein. This pooling will cause increased pressure on the veins and can result in varicose veins. Often, people may also have the same underlying cause but have different symptoms. This is because there may be different paths of backflow for different people.
Causes of Varicose Veins
The second component is the mechanism by which the blood is propelled up the leg. When the heart pumps, it gives a surge of blood flow, and each heartbeat is followed by a brief pause. These surges are transmitted to the blood in the leg through the action of muscle pumps. These are simply the calf and thigh muscles contracting and squeezing the blood up the leg. The brief pause between heartbeats allows the next valve to open and blood to move up the vein. If the flow of blood encounters a closed valve, the increased pressure can cause the vein to bulge and become twisted. This is the cause of varicose veins.
The first component of the circulatory system is the direction of blood flow. Veins in the leg are equipped with one-way valves to keep blood flowing up towards the heart. When these valves become weakened, the force of gravity can cause blood to flow back to the feet.
Varicose veins are caused by the disease called superficial venous insufficiency. Fully understanding the circulatory system and how these diseases affect it can lead to a better understanding of what causes varicose veins. The circulatory system is comprised of arteries and veins. Arteries carry blood from the heart to the rest of the body, and veins return it.
Symptoms of Varicose Veins
Symptoms of varicose veins can vary, and may include: Aching, pain, heaviness, tiredness, and swelling in the legs. Symptoms may be worse after standing or sitting for long periods of time. Throbbing or cramping in the legs. Itching around one or more of the veins. Skin changes, such as colour changes or dry, thinned skin over the vein. In some cases, more severe symptoms may occur and can include: Swelling, throbbing, and heaviness in one or both testicles. This is particularly true of large varicose veins in the scrotum which occur with standing and are relieved when the person lies down. Severe swelling and pain in the legs after standing for long periods of time. This pain is relieved by rest and elevation of the legs. Superficial thrombophlebitis – this is an inflammatory reaction with a blood clot in the vein. The vein can feel like a hard lump and be quite painful with surrounding redness and warmth of the skin. Any suspected thrombophlebitis should be referred to a doctor immediately.
Skin Changes Associated with Varicose Veins
Pigmentation changes. Most common change in the skin related to venous insufficiency. It is typically brown in colour and is the result of red blood cells and other blood products escaping from the vein and entering into the skin. Haemosiderin is a result of degradation of red blood cells. The iron is toxic to the cells responsible for pigmentation, triggering an inflammatory response and stimulating and increasing production of melanin. This hyperpigmentation, although generally painless, can cause distress to the patient due to cosmetic reasons. It is often localized around the inner aspect of the ankle, extending to the outer aspect. This is a good clinical sign that it is due to chronic venous insufficiency. It is a potential cosmetic problem for patients who have undergone successful endovenous treatment on their varicose veins and can sometimes encourage them to have further treatment. 3.2 Ulcers and Open Sores. Ulcers are a severe complication in the skin that are due to long-term untreated venous insufficiency and can affect up to 1% of people in western countries. The main cause of venous ulcers is ambulatory venous hypertension, causing microcirculatory changes in the skin, also increasing vascular permeability and causing tissue hypoxia. This then leads to an inflammatory response that damages the skin. This skin damage is the most common site of an ulcer, and even minor trauma can cause it to break down. It is a misconception that venous ulcers are infected. In fact, cellulitis and osteomyelitis are rare, and mainly bacterial infection occurs on the ulcer, creating the appearance of infection. Ulcers are typically located around the inner aspect of the ankle and are highly prone to recurring once healed. High bandaging (40mmHg) and compression hosiery have been shown to reduce occurrence and should be worn for 2 years to prevent a recurrence. Only 33% of ulcers heal within a year, and the best prognosis is from combination treatment using leg elevation, compression therapy, and surgery (if appropriate).
Pigmentation Changes
Besides the unsightly nature of the pigmentation changes, they are a sign that there is an underlying problem with the veins. The pigmentation occurs as a result of blood and iron deposits in the skin. White blood cells from the immune system attack the red blood cells in an attempt to clear them from the body. This process releases iron from the red blood cells, leaving hemosiderin deposits in the skin. Hemosiderin is a brownish pigment and what gives the skin the discolored appearance. The presence of hemosiderin in the skin is a strong indication that venous hypertension has been occurring for some time. Hemosiderin itself can potentially cause damage to the skin and is also thought to deactivate the enzyme responsible for the formation of new collagen, which may impair wound healing.
Pigmentation changes are a common skin change that occurs in areas affected by varicose veins. This generally occurs in the ankle area but can also occur in areas where there is a history of a healed or active ulcer. It is caused by the deposits of red blood cells in the skin. At first, the skin takes on a red or brown hue. At this stage, it can be difficult to determine the cause of the pigmentation changes. In time, the pigmentation can turn to a darker brown, at which point it becomes more obviously related to the varicose vein disorder. In severe cases, the skin in the ankle area can take on a metallic brown color.
Ulcers and Open Sores
Sometimes an ulcer may heal, because new skin can grow if pressure is reduced, but often new ulcers will appear as existing ulcers heal. Ulcers can become infected or form hard, painful lumps, because the intense pressure at the skin surface caused by the veins trying to push fluid out of the leg can force the tissue to create a protective barrier of scar tissue and fat.
If the leaked blood cells and fluid remain in the skin for a long time, usually several months, the skin becomes stained brown, because the iron in the red blood cells is left behind, and an ulcer may develop. This is an area of skin which has died, because it has been starved of oxygen by the leaked fluid, and it may be gradually replaced by the growth of fragile, painful tissue, because the iron in the leaked blood is a wonderful food for an enzyme produced by the tissue.
Although the cause of venous ulcers is complex, the basic problem is high blood pressure in the veins of the leg. Blood pressure rises because of small, usually painless, blood clots, which may block the veins. If the blockage is in the deep veins, then the higher pressure is transmitted to the surface veins by veins which connect surface and deep veins. These surface veins, because they are not designed to take high pressure, stretch and leak blood cells and fluid into the skin. Usually, blood is broken down in the tissues of the body and recycled. But when large amounts of red blood cells are leaked from the veins, some remain near the skin surface and are broken down by an enzyme in the skin. This enzyme is toxic to the skin and may cause an eczema-like condition with itching and redness.
Lipodermatosclerosis
Lipodermatosclerosis is a condition seen in longstanding venous disease, which frequently affects the lower legs of individuals. A history of leg swelling, heaviness, and aching is typical of affected individuals. The term lipodermatosclerosis is descriptive in that the tissue changes seen in this condition affect the dermis and subcutaneous fat. Typically, there are no skin changes over the foot, but the lower third of the leg is erythematous, often described as an inverted champagne bottle, with the red area circumferential around the ankle but sparing the latter. Over the area of erythema, the skin is indurated due to fibrosis, and hyperkeratosis is common. In advanced cases, there is hypopigmentation and in longstanding patients with severe disease, the skin may become atrophic. Lipodermatosclerosis is felt to be due to the effects of long-standing venous pressure and hypoxia and resultant inflammatory processes on the skin and subcutaneous tissues. It is a disease that has the potential for improvement with correction of the underlying venous pathology.
Recognizing and Treating Complications
Superficial thrombophlebitis This is inflammation of a varicose vein with the formation of a thrombus. It typically presents with pain and swelling in a palpable cord of the vein. There may be surrounding erythema, and the patient may have a low-grade pyrexia. It can be limited to a short segment of the vein or more extensive. If the latter is the case, it may be difficult to differentiate from a DVT. An ultrasound scan will confirm the diagnosis. High thrombus extension into the deep veins can be associated with PE. Treatment is with a non-steroidal anti-inflammatory drug (NSAID) such as ibuprofen and an anti-platelet agent. The leg should be bandaged, and the patient referred to the GP for review. Anticoagulation is not required unless there is involvement of the deep veins.
Deep vein thrombosis (DVT) In this condition, a blood clot forms in a deep vein. This typically presents with pain, tenderness, and swelling in the affected limb. The overlying skin may be discolored and warm. However, these signs can be difficult to detect, especially if the patient has a lot of surrounding edema. An ultrasound scan will confirm the diagnosis. Treatment is with graduated compression stockings if the patient is able, or with bandaging. The patient should keep the leg elevated as much as possible. Anticoagulant therapy may be initiated by the GP, but because of the risks and potential complications with drug interactions, it may be better to admit the patient for this. If there is any suspicion of a concomitant (or ‘silent’) PE, the patient should be referred to the hospital immediately.
Venous disease can produce a number of conditions which are potentially limb threatening. All of these, if presenting acutely, may be difficult to differentiate from an infection. If there is any doubt with regard to the diagnosis, the patient should be admitted to the hospital.
Deep Vein Thrombosis (DVT)
This is the form of thrombus formation in the deep veins. Often, this occurs in the setting of previous or current DVT. This is because the deep vein thrombosis damages the delicate valves in the vein. If a valve is not working, the blood will pool in the distal part of the vein. This is termed venous stasis. When the pooled blood clots, it is termed as ‘phlegmasia cerula dolens’. This is an uncommon yet painful and dangerous form of DVT. The extremity becomes very swollen, painful, pale, and the patient may develop paraesthesia. The paraesthesia is due to nerve ischemia. If the condition is left untreated, it may progress to a more serious condition called phlegmasia alba dolens, where the arterial blood supply is compromised. This is often difficult to distinguish from arterial ischemia. The most serious complication of DVT occurs when a part of the blood clot dislodges itself from the site of thrombosis, travels through the deep veins, and subsequently to the right side of the heart. From here, it can enter the pulmonary arteries. This is called a pulmonary embolism and is often fatal.
Superficial Thrombophlebitis
Superficial thrombophlebitis is clotting and inflammation within a superficial vein. The vein often feels like a hard cord under the skin and dilation of the blood vessel. Involvement of the saphenous vein is a concern because it may lead to extension of the thrombus into the deep venous system. Due to this medical concern, it is advised that patients with saphenous thrombophlebitis undergo ultrasound examination for detection of deep venous thrombosis. If the patient has a history of deep venous thrombosis or if the thrombophlebitis is close to a deep venous system, it is also recommended that patients undergo more extensive testing. Treatment may include the administration of NSAIDs to limit inflammation and pain at the site. More severe cases may require the use of anticoagulative agents. While rare, migration of a thrombus from a superficial system into a deep system distant from the site of thrombosis may cause pulmonary embolism. This concern must be taken into account when deciding on treatment and extent of testing for thrombophlebitis. Due to the effects and possible cause of migration of the thrombus, it is important to effectively treat and monitor thrombophlebitis in order to prevent more serious complications.
Venous Stasis Dermatitis
Venous stasis dermatitis occurs as a consequence of long-term edema from venous insufficiency and is the most common skin problem seen in patients over the age of 50. The skin changes of venous insufficiency can occur without a past history of visible varicose veins. Initially, there is redness of the skin due to the congestion of the small blood vessels in the skin. This can lead to itching and inflammation in the affected skin. Over time, brown discoloration of the skin will occur. This is the result of iron pigment deposits in the skin from the breakdown of red blood cells in the congested capillaries. If the condition persists without adequate treatment, this brown skin discoloration can become permanent. An area of skin with brown discoloration is prone to inflammation if there is trauma to the skin from a minor injury, sunburn, or other types of skin irritation. This inflammation of the skin is called stasis dermatitis. In severe cases, a red or rusty brown spot(s) is noticed. This is referred to as hemosiderin. A spot of leathery, waxy, brown skin suggests the presence of venous stasis ulcers, the final severe skin complication of chronic venous insufficiency. An ulcer is an open sore that can be slow and difficult to heal and can be very painful. The most frequent location for a venous stasis ulcer is above the ankle on the inside of the leg.
Cellulitis
Cellulitis is a potentially serious bacterial skin infection which can lead to life-threatening complications. It commonly affects the lower extremities in patients with chronic venous disease and is often mistaken for other complications of chronic venous disease. It presents as a rapidly spreading skin redness and is typically accompanied by pain or tenderness, a sensation of warmth and fever. Pre-existing skin changes of chronic venous disease such as hemosiderin staining and/or chronic edema predispose patients to cellulitis. An episode of cellulitis in a patient with varicose veins and/or chronic venous edema represents a breakpoint and often represents the first admission to a patient that what they considered a ‘minor’ or ‘cosmetic’ problem with their leg veins may be a more significant problem. Prompt referral and treatment of the underlying venous abnormality following the first episode of cellulitis in these patients has the potential to prevent further episodes of cellulitis and its associated morbidity.