Chronic venous insufficiency in older adults: swollen legs, skin changes and leg ulcers

NHS Lothian's clinician guidance explains that venous incompetence combined with a weak calf-muscle pump in promoting venous return results in chronic venous hypertension, with blood pooling in the veins of the legs. This may occur even without visible varicose veins. Risk is increased with age, immobility, varicose veins, leg or pelvic surgery, and after deep vein thrombosis or cellulitis of the lower leg. The guide says early diagnosis and management can reduce progression to irreversible changes and ulceration.

The NHS describes varicose veins as swollen, twisted veins under the skin, usually on the legs, which may cause aching, heaviness, itching, colour changes, dry or scaly skin and swollen ankles; symptoms are worse after standing for a long time and ease with the legs up. They may worsen without treatment, but this usually happens slowly over several years. They are different from harmless spider or thread veins.

NHS Lothian describes a sequence. Venous eczema shows as redness and brown discolouration at the ankle ("gaiter") area, with dry, itchy or weepy skin, usually in both legs; it says venous eczema affects approximately 20% of people over 70. Lipodermatosclerosis follows chronic inflammation and fibrosis, making skin hard and "woody", red-brown, sometimes with a shape the guide likens to an inverted champagne bottle, and can be more painful and make compression harder to tolerate. Venous ulceration comes next, developing slowly over months in the gaiter region.

The guide notes venous ulcers are often large but relatively painless for their size unless infected, have irregular margins and a shallow crater, in contrast to the painful, smaller "punched out" ulcers of arterial disease. Poorly controlled diabetes, smoking and obesity can compromise healing. Because arterial and venous ulcers need different treatment, a leg ulcer should always be assessed by a clinician rather than self-treated.

Patient.info says the appearance of a venous leg ulcer is usually fairly typical, and a doctor or nurse checks the blood pressure at the ankle and arm to give the ankle brachial pressure index (ABPI). A low ratio (less than 0.8) points to poor circulation from peripheral arterial disease rather than a venous cause; it adds the ABPI may be rechecked every six months or so. Blood and urine tests may rule out anaemia, diabetes, kidney problems and rheumatoid arthritis, and in complicated cases an ultrasound, CT or MRI maps the circulation.

The NHS says specialists usually do a duplex ultrasound, a scan that checks blood flow, to confirm varicose veins and plan treatment.

Patient.info explains that compression bandaging counteracts the raised pressure in the leg veins: a nurse applies 2 to 4 layers over the dressing, tightest at the ankle and gradually less towards the knee, and reapplies them about weekly. It cautions that you should still be able to move your ankle with bandages on, and should remove them and see a doctor or nurse if your foot changes colour or temperature or pain increases. Support stockings over the dressing are sometimes used as an alternative but are not thought to be as good.

When resting, keep the leg raised higher than the hip; Patient.info suggests 3 or 4 periods a day of about 30 minutes, and that the leg should be elevated before bandages are applied. It advises keeping as active as possible. The NHS says to put the legs up when possible, exercise regularly such as walking, keep to a healthy weight, avoid standing or sitting for long periods unless the feet are raised, use moisturiser for dry or itchy skin, and stop smoking.

NHS Lothian says long-term management includes compression hosiery after ABPI testing has shown no arterial insufficiency, encouraging mobility, leg elevation when seated, raising the foot of the bed overnight to reduce swelling, supporting weight loss and considering referral for venous surgery where varicose veins are present. Compression is not suitable for people with problems with arterial blood flow, which is why the check comes first.

The NHS says varicose veins do not always need treatment. A GP may refer you to a specialist if you have pain, heaviness, swelling, itching, skin changes or complications such as leg ulcers. Endothermal ablation, using radio waves or laser to heat and close the vein through a thin catheter under local anaesthetic, is usually the first choice; foam sclerotherapy is offered if ablation is not suitable; and ligation and stripping surgery is offered if simpler procedures are not suitable. Most people go home the same day and may need compression stockings for about a week. Procedures purely to improve appearance are not usually available on the NHS. Patient.info mentions that skin grafts or vein surgery may be advised for some ulcers.

Patient.info says most ulcers heal within 12 weeks with weekly compression bandaging, and that after healing a compression stocking should be worn each day to prevent recurrence, for at least five years according to its summary. Venous leg ulcers affect about 1 in 100 people in the UK at some point, it says.

The NHS says see a GP if you have varicose veins and a sore on the leg that has not healed after 2 weeks, if they are getting worse or causing pain, itching or swelling, and ask for urgent GP help or NHS 111 if varicose veins are bleeding. NHS Lothian says infection should be considered if there is a fever or a one-sided area of tender, hot redness, and Patient.info says increasing pain under bandages should prompt advice. Sudden leg swelling with pain, particularly in one leg, needs same-day medical review, as it can indicate a clot.