What Does Phlebitis of the Leg Look Like | with Pictures?
Phlebitis is an inflammation of a vein. The vein is hot, red and lumpy. The lump is tubular in shape and it is tender to touch, it may throb and walking may be painful. The cause of phlebitis in the leg is most often a clot in the vein just under the skin. It can disperse and the phlebitis then gets better, but sometimes phlebitis is serious and the condition may become dangerous.
What is Phlebitis?
The vein becomes inflamed either due to a blood clot (thrombus) or because the vein walls are damaged. For this reason, the terms phlebitis and thrombophlebitis are used almost interchangeably. There are two types of phlebitis – superficial phlebitis affects the veins close to the surface of the skin and it is not usually too serious; deep vein thrombophlebitis is much more serious and it affects the larger, deeper veins, frequently in the legs. Deep vein thrombophlebitis (DVT with inflammation) can be very serious if a blood clot breaks away and travels to the lungs, which would result in a pulmonary embolism (PE).
What does Phlebitis Look Like?
As you can see in the photograph of phlebitis, the skin over the vein is often discoloured but sometimes there may be nothing to see, particularly if the vein is a little deeper. This patient had quite a lot of tenderness. An ultrasound scan confirmed that there was clot in the vein and blood-thinning medication was prescribed (anticoagulants).
What are the symptoms of phlebitis?
In a case of superficial phlebitis, symptoms may not develop, but if they do they generally tend to be pain, sensitivity, redness and bulging of the vein. The symptoms of deep vein thrombophlebitis are similar, but pain might be experienced throughout the entire limb, or the whole limb might suddenly swell. Some might also experience a fever and feel generally unwell.
An Ultrasoud Scan is Needed in ALL Cases of Suspected Phlebitis
Ultrasound of Leg Veins: The normal vein shows as a dark circle. The vein with clot appears with a grey “lump” of clot.
What causes phlebitis?
Phlebitis is caused by blood clots which can form due to venous injury, or as a complication from a surgical procedure. There are also certain risk factors that increase the chances of a blood clot forming:
- Obesity
- Smoking
- Pregnancy
- Sedentary lifestyle
- Immobility for long periods
- Varicose veins
- Some oral contraceptives and hormone replacement therapy (HRT)
- Certain medical conditions (cancer, blood disorders)
Can phlebitis be prevented?
Although phlebitis cannot always be prevented, controlling the risk factors can help:
- Stay active and exercise frequently
- Keep well hydrated and drink water frequently
- On long flights or long journeys, consider wearing flight socks
- Stop smoking
- Lose weight (if overweight)
What is the treatment for phlebitis?
Measures for superficial phlebitis you can take (self-help measures) to treat it include:
- Keeping the leg raised
- Wear compression stockings
- Use anti-inflammatory medication such as aspirin
- Use a cold flannel to ease pain
- Keep moving to help the flow of blood
Your GP or a hospital specialist might also prescribe anticoagulants (blood-thinners) to stop additional blood clots forming and clot-dissolving medication for cases of deep vein thrombophlebitis. In some cases, the surgical removal of blood clots might be necessary or a bypass of an injured vein.
Phlebitis versus Cellulitis versus Varicose Eczema of the Leg
These three conditions may be difficult to distinguish just by looking at the leg. In phlebitis, the problem is a clot in the vein, in the case of cellulitis the problem is a bacterial infection. For phlebitis, blood thinning medication may be necessary and antibiotics are not needed. In cases of cellulitis, antibiotics are required. Both phlebitis and cellulitis are urgent and potentially very serious. Both phlebitis and cellulitis can be fatal if not treated properly.
Varicose eczema is a reaction of the skin to the damage caused by faulty leg veins. Varicose eczema can lead to a leg ulcer but it is not urgent and the ulcer (if it does occur) develops slowly. Neither antibiotics nor blood-thinning medication is required for people with varicose eczema.
The only way to accurately diagnose these three conditions is by a duplex ultrasound scan.
A Cautionary Story
In February 2021, a visitor to the website left this message:
” Dear Dr Gajraj, I am contacting you in the hope that you could give some advice and pointers on my recent development of a blood clot in my upper leg/groin area at the intersection of a superficial vein and deep vein.
Two weeks ago I experienced pain in my calf muscle on my right leg. I could feel a raised, cord-like vein near the surface of the skin. The following day I was examined at my GP surgery by a doctor who diagnosed phlebitis (I had already mentioned this to them through my own research) and prescribed a week’s course of antibiotics to fight any possible infection. At this point I asked about clots and the possibility of a clot forming, travelling up the superficial vein and into a deep vein. I was reassured this was unlikely. Two days later I spoke to a different GP via phone as the inflammation was worse, had moved up passed my knee and was now in my thigh giving rise to acute pain, redness of skin and further raised, cord-like vein which is tender to touch. I was again assured that I was on the correct treatment and vein inflammation can travel up a vein. Ice and paracetamol was suggested as pain relief. By the end of the antibiotic course one week later there was no improvement with pain and inflammation just as bad, coupled with obvious swelling and tenderness around the ankle. I was examined in person by a third doctor who was concerned that things were worse despite the full course of antibiotics. She arranged an emergency ultrasound scan at my nearest main hospital two days later (now ten days after my initial awareness of calf muscle pain). She also put me on a double dose of Apixaban 5mg ( two tablets in morning, two more twelve hours later) which I started straight away prior to the scan two days later.
The scan ( which I was able to view) revealed a clot ( I am unsure of size but it seemed fairly large relative to the neck of the deep vein) held by a thin thread to the wall of a superficial vein and oscillating in the blood flow in the neck of a deep vein in my groin area. A chest x-ray was taken at the same time as was blood for liver function ( I believe?), coagulation and a third which I forget. That was Thursday 28 January and as yet I have not heard any word back on the tests.
I have been told I will be on Apixaban for at least six months and possibly life if I have a recurrence of clotting.
I am 59 years old, generally fit and healthy, walk most days – recently 4 to 5 miles several times a week, never smoked, moderate drinker, BMI perhaps a little high but not obese at all, no recent surgery or long flights. I do have varicose eczema, diagnosed by doctors, in this leg only and have had this for 15 to 20 years, but only told to moisturise the skin daily which I have done. No other treatment has ever been explored for the eczema.
This has all come as a shock to me and still have a number of questions. Is the Apixaban the best and only way forward? If the clot breaks free and enters the lungs how dangerous is this and will Apixaban alone be enough to treat this as I am being told? What is the recovery time period for the damaged and inflamed leg? How likely is it that I have long-term damage to the veins and valves in my right leg? – I find it very difficult to straighten or weight-bear on this leg at present. What can I do by way of self-help to aid my recovery? Also, pain relief – the leg remains painful, with a burning sensation most of the time. This will be a big quality of life change for me if my leg does not substantially improve. I am raising the leg at times and taking light exercise every day – not sitting for too long, a little walking. Compression bandages have not been advised.
I apologise for the length of this enquiry but wanted to include as much detail as possible. I appreciate you may not be able to advise in any great depth here but would greatly value any general advice, reassurance or pointers for my own further research and safe self-treatment moving forward.
Many thanks for taking the time to read this and I hope you, your family and all your colleagues are safe and well in these difficult times for us all. “
This story illustrates how even in 2021, phlebitis is often misdiagnosed and more importantly it is very often mistreated.
Summary
Phlebitis is commonly misdiagnosed and more importantly it is very often mistreated.
Essential facts about phlebitis:
- Phlebitis is not caused by an infection and antibiotics are not necessary. Recent reviews in the medical literature suggest that antibiotics are frequently prescribed for phlebitis. Not only is this ineffective, but it costs our healthcare system and it may contribute to antibiotic resistance.
- Phlebitis most commonly affects the leg veins and it causes swelling, tenderness and redness along the vein. Less common sites include the arm and the chest.
- The diagnosis requires a duplex ultrasound scan. Conditions such as cellulitis can mimic phlebitis and therefore confirmation of the correct diagnosis with a duplex ultrasound scan is essential and it ensures that you get the right treatment.
- The fundamental problem causing the inflammation in the vein is clot formation which can spread to the deep veins causing a deep vein thrombosis (DVT) and pulmonary embolism (PE). Many experts suggest that the term phlebitis should be replaced by the term superficial venous thrombosis. This term more accurately describes the potential for DVT.
- The duplex ultrasound scan should not only check the area that is painful, but both legs should be examined for a possible deep vein thrombosis. When someone has phlebitis, they can be in a so-called hypercoagulable state in which the blood is sticky. That means that clots can develop elsewhere in the body, including in the deep veins of the other leg.
- Phlebitis in varicose veins often recurs and people with varicose veins and phlebitis should have treatment to deal with their varicose veins.
- Phlebitis in the absence of any varicose veins is a particularly serious condition. Some people with this condition have an unsuspected malignancy and so careful screening is needed to ensure they have cancer treatment as soon as possible.
Guidelines from both America and the UK, indicate that phlebitis in the veins in the legs can give rise to clots that travel to the lungs. These clots are called Pulmonary Emboli (PE’s) and they can be life threatening. The guidelines differ a little but in general, if the phlebitis is longer than 5 cm or within 3-5 cm of a deep vein, anticoagulation is advised.
Most patients with phlebitis are not at risk of PE’s. However without a duplex scan, it is impossible to tell which patients with Phlebitis are at risk and which patients are not.