The skin bears the brunt of leg vein disease. Nearly all leg vein problems affect the skin in some way.
By this I mean that when the leg veins do not work properly, as well as varicose veins which bulge below the skin, there are changes that are visible actually in the skin. So what are these skin changes and why are they important?
The Skin Changes Caused by Unhealthy Leg Veins:
- Spider Veins
- Oedema
- Pigmentation and Venous Eczema
- Atrophie Blanche
- Corona Phlebectatica
- Ulcers
Spider Veins:
The medical term for spider veins is telangiectasias. A recent medical review of the pathophysiology of telangiectasias of the lower legs and its implications has been published in the medical literature in Phlebology: The Journal of Venous Disease. The conclusion is – “The pathophysiology of telangiectasias remains mysterious. Several types of telangiectasias and several pathophysiological mechanisms exist. The majority of the telangiectasias are certainly secondary to reflux originating either from feeding reticular veins, from perforators, or varicose veins.”
Back flow of blood and build up of pressure in small blood vessels in the skin leads to visible spider veins.
The final pathway for the transmission of this back pressure is the associated reticular vein. The lady in the photograph has an obvious varicose vein which is “feeding” the unsightly spider veins at the back of her knee. In other cases, there may not be an obvious visible underlying problem. So, although spider veins look unimportant, they are always a sign of back flow (venous reflux), deeper, below the skin. That means that before spider veins are treated, a thorough assessement of the deeper veins is needed.
Oedema:
When there is back pressure in the capillaries, the skin and the underlying tissues become overloaded with interstitial fluid. Fluid retention in the skin is an advanced feature of leg vein problems.
Oedema is defined as a perceptible increase in volume of fluid in skin and subcutaneous tissue. When pressure is applied to areas affected by oedema, the area indents. This is often seen when the top of socks leave a dent. Venous oedema usually occurs in the ankle region, but it may extend up the leg and down to the foot.
There are many causes of oedema, such as standing or sitting for long periods of time, physical inactivity, chronic venous disease, lymphoedema, infections, heredity, pregnancy, surgery and trauma.
Oedema of venous origin occurs when blood “stagnates” in the veins, thereby preventing the capillaries from properly functioning and causing excessive fluid (water, electrolytes and proteins) to build up in the skin and subcutaneous tissue.
Venous Eczema:
Venous Eczema (also called varicose eczema) is an inflammatory reaction of the skin induced by back pressure in the leg veins which is transmitted to the skin. It is most often located near varicose veins, but it can be found anywhere on the leg. If left untreated, it can progress to blistering, weeping, or scaling eruption of the skin on the leg. It is a warning sign that a leg ulcer is likely to develop. As you can see in the photograph, the skin is discoloured and the areas can be intensely itchy. The condition will respond to steroid cream and the inflammation will settle. Steroid creams can be helpful to relieve intense symptoms, but as the condition is caused by underlying vein problems, these vein problems should be treated as soon as possible.
Long-term use of steroid creams will thin the skin and the skin will become vulnerable to injury and leg ulcers.
Pigmentation:
This is a brownish darkening of the skin due to the leakage of red blood cells from the vein into the surrounding tissue, often referred to as haemosiderin staining. It usually occurs in the ankle region, but it may extend to the leg and foot. Pigmentation may be the only sign of advancing venous disease.
Any pigmentation around the ankle, paricularly if it affects only one leg, should raise suspicions that there is underlying vein disease.
Atrophie Blanche:
Also called white atrophy, atrophie blanche is a type of scarring found on the lower leg or foot. It is a circular, pale and thin-skin area surrounded by dilated capillaries and sometimes hyperpigmentation. It is a sign of severe leg vein disease and represents a very late and advanced complication of varicose eczema where the skin has lost its nutrient blood flow.
The back pressure in the veins of the skin prevents the proper flow of oxygen and nutrients in the capillaries. If the skin does not receive nourishment, small areas essentially die and form white scars. The photograph shows the patches of white atrophy around the ankle and there is a cluster of blue veins surrounding these patches. These blue veins are called Corona Phlebectatica.
Corona Phlebectatica:
Corona phlebectatica is defined as the presence of abnormally visible cutaneous blood vessels at the ankle.
In the new International Classification of Vein Disease (CEAP Classification), it is an indicator of advanced leg vein disease.
In the early stages, corona phlebectatica may just look broken veins and some people seek treatment for purely cosmetic reasons.
The blue veins around the ankle can be injected to make them fade, but only after a careful assessment by a vein specialist. This will involve a duplex ultrasound scan to determine the cause of the condition and which treatment options might be appropriate.
Broken veins around the ankle should not be injected until an underlying vein problem has been rectified.
Venous Leg Ulcer:
This is the most feared consequence of long standing leg vein problems. A venous leg ulcer is a full-thickness defect of the skin, most frequently in the ankle region, that fails to heal spontaneously.
In the international classification of leg vein disease, a leg venous leg ulcer is the most advanced stage of complications.
An active leg ulcer is classified C6, while healed leg ulcers are classified C5 in the CEAP classification.
Venous leg ulcers are painful open lesions on the lower leg that occur in the presence of severe venous disease. The wound itself is often irregular and there may be weeping discharge as the tissue fluid seeps from the wound.
It is important to know that ulcers do not heal spontaneously and referral to a vascular specialist is needed.
In the past, venous leg ulcers were treated by prolonged periods in bandages. Recent research published in the New England Journal of Medicine called the EVRA Trial, has confirmed that treating the underlying vein problems at an early stage gets skin ulcers healed more quickly. Furthermore, the risk of the ulcer coming back is reduced if the veins are treated.
Summary
Nearly all the serious health complications of leg vein disease are manifested in the skin.
The skin changes are visible and they are an indicator of poor leg vein health. Careful assessment of these skin changes by a vein specialist leads to accurate diagnosis and the correct treatment.
In many ways, because leg vein disease manifests itself in the skin, it means that if you are affected, you can see that something is wrong with your veins. The temptation is to think that the problem is only skin deep or that the skin changes are due to a dermatological problem. The reality is that the problem is deeper in the veins.
If you would like more information about the skin changes caused by leg vein disease, please get in contact and one of our advisors will be happy to help you.