Venous disease is a common vascular disorder caused by elevated venous pressure. It is a persistent, progressive, and frequently underestimated condition that can have a huge socioeconomic, physical, and psychological impact on a person (Ortega et. al, 2021). The term venous disease describes a continuum of disorders that range from mild swelling of the legs to severe ulceration of the legs that can have a major impact on a person's quality of life.
The development of venous disease
Chronic venous disease develops because of an interplay between genetics and environmental factors that increases venous pressure, leading to substantial changes in the whole structure and functioning of the venous system (Ligi et. al, 2018)
Veins are part of the circulatory system. They return de-oxygenated blood to the heart. It is then oxygenated and circulated though the body. Veins contain valves that prevent backflow of blood. (See figure one)
Many veins, especially those in the arms and legs, have one-way valves. Each valve consists of two flaps (cusps or leaflets) with edges that meet. Blood flowing toward the heart pushes the flaps open. If gravity or muscle contractions try to pull the blood backward or if blood begins to back up in a vein, the flaps are pushed closed, so the blood does not flow backward. The valves help the return of blood to the heart, opening when the blood flows toward the heart and closing when blood might flow backward. There are superficial veins, located in the fatty layer under the skin, deep veins, located in the muscles and along the bones and short connecting veins that link the superficial and deep veins. In the legs the calf muscles compress the deep veins with every step and this pushes blood from the legs to the heart. Most (90%) of the blood from the legs is carried from the deep veins to the heart, the remaining 10% is returned, more slowly through the superficial veins (Tortora and Derrickson, 2017).
Conditions that raise venous pressure can damage the deep veins in the legs. These include pregnancy; obesity; abdominal tumours; or direct injury such as a thrombosis in one of the deep veins in the legs (deep vein thrombosis). High pressure stretches and pushes the valves apart and they become damaged and no longer work effectively. This leads to a further increase in pressure and failure of the next valve along. This leads to established high pressure in the veins – chronic venous hypertension – causing back flow of blood into the thin walled superficial veins. The superficial veins become stretched and dilated. This causes further back flow of blood and increased pressure in the superficial veins and capillary distension. Capillary distension leads to blood and plasma leaking into the tissues. It is thought that this leads to an inflammatory reaction resulting in venous eczema and skin damage (British Association of Dermatologists, 2016; CKS, 2022; NHS Choices, 2023; Oakley, 2016).
The continuum of venous disease
Venous eczema is part of a continuum of venous disease known as the Clinical Etiological Anatomical Pathological (CEAP) classification. This classification was updated in 2020 and included new categories for corona phlebectatica(C4c), recurrent varicose veins (C2r), and recurrent leg ulceration (C6r). Corona phlebectatica is defined as ‘the presence of abnormally visible cutaneous blood vessels at the ankle with four components: “venous cups,” blue and red telangiectases, and capillary “stasis spots”’ (Uhl et. al, 2012). Table 1 provides details.
Table one. CEAP classification chronic venous disorders
| Class | Description |
| C0 | No visible or palpable signs of venous disease |
| C1 | Telangiectasia (spider veins) or reticular veins |
| C2 | Varicose veins, distinguished from reticular veins by a diameter of 3mm or more. |
| C2r | Recurrent varicose veins |
| C3 | Oedema |
| C4 | Changes in skin and subcutaneous tissue secondary to chronic venous disease, divided into 3 sub-classes to better define the differing severity of venous disease: |
| C4a | Pigmentation or eczema |
| C4b | Lipodermatosclerosis or atrophie blanche |
| C4c | Corona phlebectatica |
| C5 | Healed venous ulcer |
| C6 | Active venous ulcer |
| C6r | Recurrent active venous ulcer |
The CEAP classification is used to determine the level and severity of venous disease, to manage venous disease and reduce the risks of disease progression.
The venous clinical severity score (VCSS) is used to complement the CEAP classification.
The score includes 10 clinical parameters (pain, varicose veins, venous oedema, skin hyperpigmentation, inflammation, induration, number of ulcers, durations of ulcers, size of ulcers, and compliance with compression therapy). Each item is graded from zero to three depending on severity None = 0, Mild = 1, Moderate = 2, Severe = 3. The person with venous eczema for example may have mild eczema limited to perimalleolar area or severe eczema affecting the lower third of the calf (Vasquez et al, 2010).
What is venous eczema
‘Venous eczema (also known as varicose, gravitational, or stasis eczema) is an inflammatory condition characterized by red, itchy, scaly, or flaky skin, which may have blisters and crusts on the surface.’
(CKS 2022).
It is important to be aware that a non-infective inflammatory condition such as venous eczema is often misdiagnosed as cellulitis (Nazarko, 2022).
Prevalence of venous disease
It is difficult to determine prevalence as studies vary due to differing definitions. Research suggests that venous disease becomes more common as people age and that 20% of people aged 70 and over have venous eczema (Oakley et al, 2016). ONS (2022) data indicates that at least 1.83 million people in the UK aged 70 and over have venous eczema.
If we apply these figures to the UK population then around 17 million adults in the UK have venous disease and around 2 million of those have venous eczema (ONS, 2017). In 2017-2018 Community nurses cared for over 1 million people with leg ulcers, 58% had a venous leg ulcer (around 603,200 people) (Guest et. al, 2015: Guest et. al, 2020: Guest et. al, 2022). Around 37-44% of people with level C6 disease (active venous ulceration) have venous eczema (Patel et al, 2001). If we take the lower estimate that gives 223,284, so over 2 million people in UK have venous eczema.
Women are at greater risk of developing venous disease than men and Caucasians are at greater risk than people of other ethnicities (Salim et al, 2021). Risk factors include ageing, obesity, immobility, varicose veins, venous thromboembolism, pregnancy, abdominal tumours and cellulitis. The number of people with advanced venous disease is rising because of population ageing, falling activity levels among the population and increasing numbers of overweight and obese adults.
Ageing is associated with increased levels of venous disease as the cardiovascular system becomes less efficient, the valves in the veins deteriorate and low grade inflammation becomes more common Molnár, et. al, 2021).
People become less active as they age (Guthold et. al, 2018). Activity levels in the UK population have fallen by 20% since the 1960s and are predicted to fall by 35% by 2030 (Office for Health Improvement and Disparities [OHID] 2022).
Overweight and obesity is now prevalent in the UK and the majority of adults aged 35 and over are overweight or obese. A body mass index of between 25 and 30 is classified as overweight 25 and obesity is defined as having a BMI of 30 or above (NHS digital, 2022). Obesity increases the risk of venous disease 6.2 times (Hotoleanu, 2020). Figure two illustrates the percentage of adults who are overweight and obese by age.
Diagnosis
Sometimes people with venous eczema are misdiagnosed as having ‘bilateral cellulitis’. The person may be treated with antibiotics at home or even admitted to hospital for intravenous antibiotics. The redness and swelling often resolve with bedrest and elevation of the legs. The person is considered cured and discharged. The person may be frequently admitted to hospital for recurrent cellulitis this exposes the person to the hazards of hospitalisation and inappropriate antibiotic therapy and fails to recognise and address the real issues (O'Brien 2021).
Cellulitis of both legs is ‘as rare as hen's teeth’, when both legs are affected clinicians should consider venous eczema, contact dermatitis and lipodermatosclerosis as more likely diagnoses (Tidman, 2012). The most common cause of bilateral red legs is venous eaczema (Levell et al, 2011).
Table 2 outlines the features of lipodermatosclerosis, venous eczema and cellulitis.
Table two. Clinical features of Lipodermatosclerosis, Venous eczema and Cellulitis
| Lipodermatosclerosis | Venous Eczema | Cellulitis | |
|---|---|---|---|
| Symptoms | No fever | No fever | May have fever |
| Pain and discomfort | Itching | Painful | |
| History of varicose veins or deep vein thrombosis | History of varicose veins or deep vein thrombosis | No relevant history | |
| Signs | Does not feel generally unwell | Normal temperature | May experience chills, sweaty, feel unwell |
| Bilateral | Bilateral | Unilateral | |
| Erythematous, inflamed | Erythematous, inflamed | Erythematous, inflamed | |
| No tenderness | No tenderness | Tenderness | |
| Hardening and thickening of the skin | Vesicles | One, or a few, bullae | |
| Woody feel to skin | Crusting | Skin does not feel woody | |
| Small white star shaped scarred areas (atrophie blanche) | Lesions on other parts of the body, particularly other leg and arms | Absent | |
| Changes in pigment may be present (haemosiderin staining) | Changes in pigment may be present (haemosiderin staining) | Absent | |
| Legs shaped like inverted champagne bottles | Varicose veins may be present | Leg shape normal | |
| Lesions on other leg | Lesions on other leg | No lesions elsewhere | |
| Portal of entry | Not applicable | Not applicable | Usually unknown, but break in skin, ulcers, trauma, athlete's foot implicated |
| Investigations |
|
|
|
| Blood culture negative | Blood culture negative | Blood culture usually negative |
Holistic care
When venous eczema is diagnosed it is important to provide holistic care. This involves caring for the skin, treating swelling, promoting health and preventing deterioration and when appropriate referring for treatment of venous disease. Figure 3 illustrates this.
Skin care
Skin care is crucially important. Common problems include, dryness, itching, scale infected venous eczema and weeping eczema. Skin can be very dry and covered in scale.
Chronic eczema causes skin changes such as dryness and thickened areas of skin. This is known as lichenification. Hyperkeratotic (thickened areas of scale and skin) skin should be removed to promote comfort and skin health as it can act as a focus for infection. Legs can be soaked in a bucket of warm water, a square bucket that accommodates both legs to mid calf is ideal. Skin can be washed with a wet disposable cloth and an emollient such as diprobase, double base or zerobase used instead of soap. Soaking and washing the skin will help remove dry scale. The skin should then be dried and an emollient applied.
Mechanical debridement using wet or dry gauze is now considered to be potentially harmful. Special pads and cloths are now available. These include Debrisoft, from Activa Healthcare, the Prontosan Debridement Pad (B Braun) and CleanWnd (Regen Medical). These all have a fleece-like contact layer to mechanically remove debris, necrotic tissue, slough and exudate. These can be used on three occasions, approximately four days apart. In the author's experience a single treatment can often be effective. The UCS debridement cloth – a pre-moistened single-use cloth from Medi UK – can also be used to debride wounds and remove scale from the skin. It has a mild cleansing agent that moistens and softens, making debridement more effective.
A single treatment can provide significant debridement and does not cause pain or discomfort. It can be especially useful in removing dry dead tissue on legs. Emollient therapy is more effective when scale and lichenified skin is removed as emollients can penetrate the skin and hydrate it more effectively.
Emollient therapy in maintaining skin health
Emollient therapy is essential. It maintains skin hydration and health and reduces the risks of flare ups, infection and the development of scale. Prescribing decisions should be based on a number of factors including skin condition and patient preference. These are summarised in table 3. The stickiness and thickness of an emollient is a good guide to lipid content. Lotions are light and easily absorbed and have the lowest lipid content. Creams have higher lipid content. Ointments have the highest lipid content. It is important to provide a preparation that the patient finds effective and acceptable (CKS, 2024; CKS 2023)
Table three. Summary of CKS (2023 & 2024) guidance on emollient prescribing
| Consideration | Recommendation |
|---|---|
| Dryness of skin |
|
| Weeping dermatitis |
|
| Frequency of application |
|
| Choice and acceptability |
|
| Efficacy and acceptance |
|
| One size does not fit all |
|
| Balancing acceptability and effectiveness |
|
Sometimes people with dry skin do not apply emollients frequently enough and the skin remains dry. Figure 4 provides details of how effective emollients are. Patients should be advised not to smoke or come in contact with naked flames when using paraffin based emollients (MHRA, 2020)
Treating red itchy inflamed skin: the role of topical steroids in managing flare ups
Steroids are used in conjunction with emollients to treat acute and subacute flare ups of eczema. The order in which these should be applied is contested however they should be applied 30 minutes apart It is important that the prescriber is able to differentiate between haemosiderin staining and inflammation. Pigmentation changes develop because high venous pressure causes blood to leak from the capillaries into the tissues. The haemoglobin in the blood is oxidised and haemosiderin deposition occurs. This leads to pigmentation changes and the skin on the lower legs becomes red or brown. Clinicians can misinterpret the colour change as indicative of infection despite the lack of clinical indications of infection (Graham et al, 2003). Clinically staining looks brown or reddish brown and inflamed skin is redder. Skin that is stained feels and looks smooth. Inflamed skin feels and looks a little lumpy and bumpy.
Steroids are an essential aspect of treatment of severe venous eczema Topical steroids are classified according to potency. Steroid creams are usually applied daily. Application of potent steroids, such as betamethasone valerate 0.1%, will flatten raised red patches of skin and treat inflammation (Oakley, 2016). They should be applied for at least two weeks as discontinuing early can lead to a recurrence of problems. Steroids are most effective when used in acute episodes of eczema. Long term use should be avoided as they can cause the skin to thin.
It is important to apply sufficient cream to treat skin effectively. Finlay et al (1989) developed a practical way to work out how much steroid cream to apply. The fingertip unit (FTU) is 0.5g of ointment. An adult lower leg requires approximately three FTUs.
Treat swelling
Compression hosiery can help those who are unsuitable for or who are awaiting treatment for the varicose veins that led to venous eczema. People with venous eczema often have aching swollen legs because the venous pump action is infective. The swelling increases the risks of skin deterioration.
If swelling is severe compression bandages can be used to reduce swelling. When swelling has settled compression stockings can be used to control swelling and alleviate pain on a long term basis (Oakley, 2016). An assessment should be carried out to determine if it is safe to apply compression. This should include using a hand-held Doppler to calculate the ankle brachial pressure index (ABPI) This assessment should be carried out by a trained and competent practitioner (CKS, 2022). Compression should not be used if there are contraindications such as peripheral arterial disease (PAD). Normally compression stockings are recommended, grade three compression is most effective but least well tolerated. Grade two are normally offered and if the person is unable to tolerate grade one, light compression, is offered.
Health promotion
Its important to work with the person to promote health and well being. This includes advice on weight loss if overweight, avoiding prolonged standing and exercise. Walking and exercises such as ankle dorsiflexion and plantar flexion increase venous return and this helps maintain skin health. The person should be advised not to sit with legs crossed and to elevate legs when possible (British Association of Dermatologists, 2016).
Advise the person to elevate the legs above the level of the hips to reduce swelling. At night the person should be advised to elevate the foot of the bed. This can be done by puting pillows under the mattress.
Refer for treatment
CKS (2022) guidance recommends that people who have primary or symptomatic recurrent varicose veins, lower-limb skin changes, such as pigmentation or eczema, superficial vein thrombosis and suspected venous incompetence, venous ulcers or a healed venous leg ulcer should be referred for assessment and treatment in a vascular service. NICE recommends a range of treatment, dependent on the severity of varicose veins. Treatments include: endothermal ablation; endovenous laser treatment of the long saphenous vein; ultrasound guided foam sclerotherapy; and surgery. Evidence suggests that many providers do not adhere to NICE guidance and there are substantial geographical variations in the provision of treatment (Michaels et al, 2022).
Conclusion
Advanced venous disease can affect quality of life and it is important that the nurse ensures that treatment is managing any issues effectively. This will enable the nurse to work with the person who has venous disease to treat existing problems and manage venous disease well to reduce the risk of ulceration and improve well-being.
KEY POINTS:
- Venous disease is common in adults
- The prevalence of venous disease rises with age
- Changes caused by venous disease can lead to pain, discomfort and deteriorating health
- Lifestyle changes can improve well-being
- Effective management can treat complications and improve comfort.