Changes in skin color and texture are some of many different complications of varicose veins. Skin discoloration from varicose veins usually happens during the most advanced stages of venous insufficiency and venous disease. Venous insufficiency and chronic venous disease leads to inflammatory changes within the walls of the varicose veins. Prolonged inflammation along these areas leads to changes in the skin which causes areas of discoloration.
Explaining the causes of skin discoloration from varicose veins requires we understand venous insufficiency. Venous insufficiency is a chronic condition caused by damage to the valves within our leg veins. Damage to these valves may occur because of genetics, prolong standing, weight gain and pregnancy. These damaged valves cause the pressure to rise within the leg veins. This is termed venous hypertension. Venous hypertension will lead to vein engorgement, vein bulging and inevitably inflammation. It's this inflammation that will start to cause changes in the skin that over time will lead to areas of discoloration.
Skin changes can vary greatly from venous insufficiency and varicose vein disease. Initially the patient may only notice the vein bulging which may appear worse if they have been sitting or standing all day. This may go on for years before there is progression and worsening of the valves and increase in inflammation. This inflammation may present in different ways for different people. The inflammation initially starts in the vein walls and may present with symptoms of aching pain, heaviness, fatigue, cramping or swelling. As the inflammation worsens, it may extend to the overlying skin. This patient may now start to notice skin itchiness or even tiny little red dots representing venous stasis dermatitis. Not everyone may present with dermatitis or itchiness. Some may start by noting areas of reddish or purplish discoloration. This would represent underlying skin hyperpigmentation.
Hyperpigmentation is often a reason for patients to search for a vein expert and can cause significant emotional distress once it begins. It usually involves the ankles and may coalesce and extend up towards the calf. Hyperpigmentation occurs in later stages of vein disease and represents stage 4 in the CEAP classification of vein disease. The elevated pressure within the veins, occurring because of progression of valve damage in the veins, leads to red blood cells being squeezed out of the leg veins and being broken down beneath the skin. This breakdown of the red blood cells leads to deposition of hemosiderin beneath the skin which leads to areas of darker redness or a purplish appearance. This process is slowly progressive and will continue until the underlying venous insufficiency is treated. Hyperpigmentation is usually permanent but can slightly improve once the underlying vein disease is corrected.
Skin discoloration from varicose vein disease comes in a few different flavors. They may present in isolation or in association with other types depending on genetics and the severity of vein disease. It may present as darker reddish and purplish areas representing previously described hyperpigmentation. Some patients develop venous stasis dermatitis, which presents with itchy small red spots, usually along the anterior calf. Some may have brownish areas which may be spotted or confluent. These areas microscopically correspond to regions of fatty deposits within the connective tissues. If there is associated adjacent scarring, then we are looking at a case of lipodermatosclerosis. Some may actually see areas of white scarring or atrophie blanche. All of these different skin findings and color changes share one common factor, underlying inflammation. Inflammation in the surrounding tissues from venous insufficiency can cause the body and skin to respond in different ways for different people. But if left untreated, most will see a progression of disease and worsening in skin discoloration over time.
Skin discoloration and symptoms also share the common factor of inflammation. Initially patients may only find the presence of spider or varicose veins but are otherwise asymptomatic. Things may remain unchanged until another factor starts to play a role, like pregnancy or a new standing job, maybe an increase in weight or decrease in physical activity. Symptoms like a dull ache in the legs, night cramping, restless legs, or some swelling in the ankles may be the start of venous insufficiency. Most people don’t seek help at this point, until these symptoms worsen or start to wake them up at night. Commonly people will feel itchy over areas of spider and varicose veins. This itchiness is also related to inflammation from the underlying varicose veins. Some may itch until they break the skin leading to some bleeding. The area remains itchy and don't heal like usual. As this area heals a small area of darkening begins. This may represent the beginning of skin discoloration. As the skin discoloration and inflammation progress, so do the symptoms of venous insufficiency. This is the usual point when patients seek help for their complaints. If they wait even longer, things may progress significantly and lead to a venous ulcer. The longer the venous ulcer is left untreated, the more likely the patient will be dealing with their ulcer for life.
Unfortunately, skin discoloration from untreated varicose vein disease is usually permanent. The goal of varicose vein treatment is to stop the underlying process causing the skin discoloration. If you have started observing changes to your skin because of varicose veins, it is better to seek advice of a vein specialist sooner than later. You will likely need a diagnostic ultrasound with a registered vascular specialist to determine the underlying cause of the varicose veins and skin discoloration. The ultrasound usually takes 30 minutes per leg. The treatment will most likely consist of both topical skin care and treatment to eliminate the underlying venous disease. Treatment of the underlying vein disease has dramatically improved over the past two decades and is now performed as an outpatient with no downtime and return to normal activities the same day. Radiofrequency ablation, endovenous laser ablation, venaseal and sclerotherapy represent some of latest treatment options for symptomatic venous insufficiency.
Visit the Center for Varicose Veins, if you are considering minimally invasive treatments for your varicose veins and venous insufficiency. Dr. Madan has over 25 years of experience in treating vein disease and is board certified in Vascular/Interventional Radiology and Phlebology.