Intended for healthcare professionals

Practice Guidelines

Diagnosis and management of varicose veins in the legs: summary of NICE guidance

BMJ 2013; 347 doi: (Published 24 July 2013) Cite this as: BMJ 2013;347:f4279
  1. Grace Marsden, senior health economist1,
  2. Mark Perry, research fellow1,
  3. Kate Kelley, associate director1,
  4. Alun H Davies, professor of vascular surgery and honorary consultant surgeon2
  5. on behalf of the Guideline Development Group
  1. 1Royal College of Physicians, National Clinical Guideline Centre, London NW1 4LE, UK
  2. 2Section of Vascular Surgery, Imperial College, Charing Cross Hospital, London W6 8RF, UK
  1. Correspondence to: G Marsden grace.marsden{at}

Varicose veins in the lower limbs are a common problem, estimated to affect at least a third of the UK population.1 Although some individuals with varicose veins remain asymptomatic, others may experience pain, aching, heaviness, and itching, that can impair quality of life.2 3 About 10% of people with varicose veins go on to develop skin changes, such as pigmentation or eczema,4 while about 3% may develop venous ulcers.5 At present there is substantial variation across the UK as to who qualifies for referral or treatment, and how varicose veins are treated.6 Clear guidance on which individuals should be referred to specialist vascular services, as well as the most clinically effective and cost effective treatment, is required.

This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE).7


NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Referral to a vascular service

  • Refer people with bleeding varicose veins to a vascular service immediately. [Based on the experience and opinion of the Guideline Development Group (GDG)]

Refer people to a vascular service if they have any of the following:

  • Primary or recurrent varicose veins that are symptomatic (associated with troublesome lower limb symptoms such as pain, swelling, heaviness, or itching) or associated with lower limb skin changes (such as pigmentation or eczema) thought to be caused by chronic venous insufficiency. [Based on moderate to very low quality evidence from prognostic studies, low to very low evidence from randomised controlled trials and corresponding cost effectiveness analysis of interventional treatment for varicose …

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