Intended for healthcare professionals

Practice Practice Pointer

Varicose veins in primary care

BMJ 2020; 370 doi: (Published 07 July 2020) Cite this as: BMJ 2020;370:m2509
  1. Eleanor Atkins, vascular surgery registrar1,
  2. Nadeem A Mughal, vascular surgery registrar2,
  3. Fiona Place, general practitioner3,
  4. Patrick A Coughlin, vascular surgery consultant4
  1. 1East Suffolk and North Essex NHS Foundation Trust, Colchester, UK
  2. 2Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
  3. 3The Rookery Medical Centre, Newmarket, UK
  4. 4Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  1. Correspondence to: E R Atkins eleanor.atkins{at}

What you need to know

  • Varicose veins are a cause of chronic venous hypertension

  • Lower limb ulceration is the most severe consequence of chronic venous insufficiency or hypertension

  • Refer patients to secondary care if there is external bleeding, ulceration (including healed ulceration), thrombophlebitis, venous skin changes, or symptoms affecting quality of life

A 62 year old woman presents to her general practitioner with bilateral lower leg swelling and aching. She has extensive varicose veins on both legs which developed during her last pregnancy, 25 years ago. She has experienced increasing discomfort in both legs over the past five years and lower leg swelling which worsens during the day. She has started to develop some eczematous skin changes around the ankle of the right leg.

Annually, 1-2% of people with skin changes related to varicose veins develop lower limb ulceration,1 which affects their quality of life and creates socioeconomic burdens on health services.1 Each year up to 7% of people with varicose veins develop lower leg skin changes (such as haemosiderin deposition and/or lipodermatosclerosis),1 which are a sign that they are at increased risk of slow wound healing and ulceration. Ulceration and skin changes are both signs of chronic venous insufficiency and require treatment. Timely specialist referral can reduce the impact on quality of life and reduce costs.2

This article offers guidance to general practitioners and non-specialists on the assessment of patients presenting with varicose veins, how to recognise chronic venous insufficiency, when to refer to secondary care, and appropriate management strategies that can be initiated in primary care. We also provide a summary of management options that might be considered in secondary care.

The advice offered in this paper is based on our clinical experience as well as the limited evidence that is available on non-specialist assessment and management of varicose …

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