GPAtlas🧭 When to suspect
Suspect varicose veins when a patient has visible, dilated, tortuous superficial veins in the legs – usually > 3 mm in diameter with the patient standing – reflecting superficial venous insufficiency, where incompetent valves allow blood to reflux and pool. They are very common in adults, so the clinical question is rarely whether varicose veins are present but whether they are symptomatic or have caused complications.
When symptoms occur they typically include aching, heaviness, throbbing or discomfort in the legs, classically worse at the end of the day or after prolonged standing, and relieved by elevation. Associated features include ankle swelling, itching, restless legs and nocturnal cramps, while more advanced disease shows skin changes (hyperpigmentation, venous eczema, lipodermatosclerosis) and ultimately venous ulceration.
Although often viewed as cosmetic, varicose veins can impair physical, psychological and social quality of life and can progress to bleeding, thrombophlebitis, skin damage and ulceration. The clinical skill in primary care is twofold: identify symptomatic or complicated disease that warrants referral, and recognise the emergencies – bleeding, ulceration, and a possible secondary cause.
| Vein type | Diameter | Features |
|---|---|---|
| Telangiectasia (thread / spider veins) | < 1 mm | Fine intradermal vessels; almost always a cosmetic concern only. |
| Reticular veins | 1–3 mm | Bluish subdermal veins; usually asymptomatic. |
| Varicose veins | > 3 mm | Dilated, tortuous, often palpable superficial veins indicating venous insufficiency – the type that may be symptomatic or progress. |
|
🧠 Clinical pearl Most varicose veins are primary and broadly bilateral. Be suspicious of unilateral, asymmetrical, or recent-onset varicosities – these can reflect a secondary cause obstructing venous outflow, such as a pelvic or abdominal mass or a previous DVT. Always examine the abdomen and ask about red-flag systemic symptoms in this group. |
Source: NICE CG168
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