Around 19% of adults have venous disease in the UK, and the number of people with venous leg ulcers has doubled in 10 years due to an ageing population, rising levels of obesity and falling levels of activity (Franks et al, 2016: All Party Parliamentary Group (APPG) on Vascular and Venous Disease, 2023; National Institute for Health and Care Excellence (NICE, 2024).
The most common causes of chronic leg oedema are venous disease and lymphoedema. These may be under-reported, underdiagnosed and poorly managed, and can lead to venous leg ulcers and infections such as cellulitis (Lymphoedema Support Network, 2022). The NHS spends £2.7 billion annually on treating venous leg ulcers (APPG on Vascular and Venous Disease, 2023).
Prevalence of venous disease
It is difficult to determine the prevalence of venous disease as studies vary due to differing definitions. Research suggests that it becomes more common as people age, but there is little specific research on venous disease and older people.
Sinikumpu et al (2021), in a study of 522 people aged 70 and over, found that around 54% had venous disease. Most (22.1%) had stage C1; 8.2% had stage C3; 7.8% had stage C4; 0.4% had stage C5; and 0.5% had stage C6. The prevalence and severity of venous disease increased with age. The Office for National Statistics (ONS) has indicated that there are 9 138 134 people in the UK aged 70 and over; therefore, at least 4.93 million people may have venous disease (ONS, 2022).
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). The UK population has become less active in recent years, with activity levels falling by 20% since the 1960s and predicted to fall by 35% by 2030 (Office for Health Improvement and Disparities (OHID), (2022). Adults tend to become less active as they age (Guthold et al, 2018).
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 (BMI) of between 25 and 30 is classified as overweight and obesity is defined as 30 or above (NHS Digital, 2022). Obesity increases the risk of venous disease 6.2 times (Hotoleanu, 2020).
Women are at greater risk of developing venous disease than men and Caucasians are at greater risk than people of other ethnicities. Risk factors include ageing, obesity, immobility, varicose veins, venous thromboembolism, pregnancy, abdominal tumours and cellulitis (Matic et al, 2019; Aslam et al, 2022).
Understanding venous disease
‘Chronic venous disease (CVD) is defined by morphological and functional abnormalities of the venous system that primarily affect the lower extremities, and present as leg heaviness/achiness, oedema, telangiectasia and varicose veins. Persistent ambulatory venous hypertension and the ensuing inflammation are the pathophysiological alterations that underlie CVD’ (Singh and Zahra, 2024).
The term ‘venous disease’ describes a continuum of disorders that range from mild swelling to severe ulceration of the legs. Venous disease is a persistent, progressive and frequently underestimated condition that can have a huge impact on a person's quality of life (Ortega et al, 2021). CVD develops because of an interplay between genetics and environmental factors that increase venous pressure, leading to substantial changes in the whole structure and functioning of the venous system (Ligi et al, 2018).
Veins return de-oxygenated blood to the heart. It is then oxygenated and circulated though the body. Veins contain valves that prevent backflow of blood (Figure 1). Many veins have one-way valves. Each valve consists of two flaps with edges that meet. Blood flowing towards the heart pushes the flaps open. If gravity or muscle contractions try to pull the blood backwards, or if blood begins to back up in a vein, the flaps are pushed closed, so the blood does not flow backwards.
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%) blood from the legs is carried from the deep veins to the heart, and the remaining 10% is returned more slowly through the superficial veins (Tortora and Derrickson, 2017).
Raised venous pressure can damage the deep veins in the legs. Causes include pregnancy, obesity, abdominal tumours or direct injury, such as a thrombosis in one of the deep veins in the legs. The 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, and causes high pressure in the veins.
Chronic venous hypertension leads to backflow of blood into the thin walled superficial veins. The superficial veins become stretched and dilated, and this causes further backflow 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 causes an inflammatory reaction, resulting in venous eczema and skin damage (Uhl et al, 2012; British Association of Dermatologists (BAD), 2016; Oakley, 2016; NICE, 2022).
How venous disease is classified
Venous disease is determined using the Clinical Etiological Anatomical Pathological (CEAP) classification. This was updated in 2020 to include 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; Lurie et al, 2020) (Table 1).
| 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 3 mm or more |
| C2r | Recurrent varicose veins |
| C3 | Oedema |
| C4 | Changes in skin and subcutaneous tissue secondary to chronic venous disease, divided into three 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 0–3 depending on severity, with 0 none and 3 severe (Vasquez et al, 2010).
Clinical features
People with venous insufficiency may initially experience no symptoms. As venous disease progresses, the person may have aching, cramping, throbbing, burning or heaviness in the leg. Pain is typical of deep venous insufficiency.
Clinical features include pitting oedema around the ankle that is worse at the end of the day, malleolar flare on the inner aspect of the ankle and instep, fan-shaped distribution of blue and red telangiectasis, superficial venules, dusky staining to the skin caused by haemosiderin deposition, visible varicose veins, increased leg swelling and skin ulceration (Caesar, 2020) (Figure 2).
Understanding lymphoedema
‘Lymphoedema is a swelling that develops as a result of an impaired lymphatic system’ (Hardy and Mortimer, 2019). The swelling in lymphoedema is caused not just by fluid, but also by fat, inflammation and fibrosis. The swelling has both fluid and solid components and it is the solid component that makes it so difficult to treat (Hardy and Mortimer, 2019).
The healthy heart pumps strongly, and pressure in the capillaries (the smallest of the body's blood vessels) is high. Around 20–30 litres of plasma leak from the capillaries into the interstitial spaces (the spaces between the cells under the skin) each day. The lymphatic system drains this fluid and returns it to the cardiovascular system (Stanton, 2000). Lymphoedema occurs when the lymphatic system is damaged; this fluid cannot be drained and builds up in the interstitial spaces.
There are two kinds of lymphoedema: primary and secondary. Primary lymphoedema may be present at birth (lymphoedema congenita) or develop from the ages of 2–35 (lymphoedema praecox) or after 35 years (lymphoedema tarda) (Moffatt et al, 2017). Secondary lymphoedema develops because of damage to the lymphatic system. Causes of secondary lymphoedema include cancers, lymphatic system trauma, infection and inflammation, parasitic infection and obesity (Chopra et al, 2015; Rockson et al, 2019; British Lymphology Society, 2021). Filarial infection is a tropical disease transmitted through the bite of an infected mosquito. It affects 54.1 million people worldwide. The filarial worms damage the lymphatic system. Infection can be treated with drugs (World Health Organization, 2021).
Obesity, especially morbid obesity (defined as a BMI over 40), can overwhelm the lymphatic system and excess weight can crush lymph nodes (O'Malley et al, 2015). Obesity is related to deprivation, and adults living in the most deprived areas are the most likely to be obese. This difference is particularly pronounced for women – 39% of women in the most deprived areas are obese compared with 22% in the least deprived (NHS Digital, 2020).
Chronic oedema may co-exist with lymphoedema and can be complicated by other conditions, including venous disease, immobility and cardiac failure. Lymphoedema in older people can coexist with other conditions, such as immobility, that lead to oedema (Cooper, 2010). All oedema, regardless of the cause, exists in the tissues whenever capillary filtration exceeds lymphatic drainage (Cooper-Stanton, 2018) (Figure 3).
Clinical features
Lymphoedema is under-recognised and undertreated (Keast et al, 2015). Early diagnosis and active treatment reduce complications and improve the quality of life for the person with lymphoedema. It is important that clinicians can determine the cause of oedema as treatments differ. The most common causes of peripheral oedema are cardiac, renal, hepatic or venous disease (British Lymphology Society, 2021).
Initially, diagnosis of lymphoedema can be difficult. When the leg is elevated the oedema may improve; as lymphoedema progresses and fluid becomes established in the interstitial tissues, clinical features change. The oedema does not pit on finger pressure and it is not relieved by elevation. As disease progresses, the leg begins to lose its shape. If lymphoedema is left untreated and the swelling worsens, skin changes may occur. The skin may thicken and develop folds, bulges and dry warty spots (elephantiasis nostras verruciformis or lymphatic papillomatosis) (Ngan, 2021).
Lymphoedema is diagnosed on the basis of history and clinical features (Table 2). The person with lymphoedema may find the limb feels tight and heavy, and have pins and needles, shooting pains or feel the limb is hot. The joints on the affected limb may feel tender and ache. The person has a reduced range of movement in the affected limb. The legs are more prone to severe oedema. Heaviness in the leg can reduce mobility and immobility can lead to further swelling, weight gain and deterioration in quality of life.
| Clinical feature | Details |
|---|---|
| Positive Stemmer's sign | It is not possible to pinch a fold of skin at the root of the second toe |
| Oedema | More than 3 months' duration. Does not reduce completely on elevation |
| Fibrosis | Skin is hard and tight and does not pit because fibrous tissue has formed in interstitial space |
| Papillomatosis | The affected skin looks like cobblestones because of lymphatic dilation and fibrous tissue formation |
| Hyperkeratosis | Skin is scaled and thickened |
| Lymphangio | Small blisters and bumps on the skin. These may burst and leak lymph fluid |
| Lymphorrhoea | Leakage of lymph fluid from the skin |
Care for people with venous and lymphatic disease
It is important that clinicians support the person with lymphatic disease to adopt a lifestyle that will help manage their condition well. Weight control is important as increased weight worsens lymphoedema, venous disease and general health (NHS, 2023). The clinician should encourage the person to lose weight and adopt a healthy diet if overweight or obese, as weight loss helps in both conditions, and this can require great sensitivity.
The person should be encouraged to become more active as moving around helps reduce oedema. Medication review is important because some medicines can contribute to leg oedema. Long-term conditions should be reviewed to ensure that they are managed as well as possible. Managing any long-term conditions well can enable the inactive person to become more active.
Venous disease management and treatment
The essentials of managing venous disease are to care for skin and to manage oedema by using compression. Skin should be washed using emollients and these should also be used to moisturise skin. Compression bandaging or hosiery can be used to reduce and manage oedema. An assessment should be carried out to determine whether it is safe to apply compression. This should include using a hand-held Doppler to calculate the ankle brachial pressure index (ABPI). The assessment should be carried out by a trained and competent practitioner.
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 is normally offered; and if the person is unable to tolerate this, grade one – light compression – is offered (Oakley, 2016).
NICE 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 to 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; APPG on Vascular and Venous Disease, 2023).
Lymphoedema management and treatment
Lymphoedema is a chronic condition and requires lifelong treatment. The four fundamental aspects of treatment are skin care, lymphatic drainage, compression garments and exercise (Ngan, 2021) (Figure 4). Prescribed medication can cause or worsen existing chronic oedema. The most common medicines that can contribute to oedema are: calcium channel antagonists such as amlodipine (used to treat high blood pressure), corticosteroids; nonsteroidal anti-inflammatories (NSAIDs); alpha-blockers (used to treat hypertension, prostatic hypertrophy and depression) and sex hormones (Keeley, 2008). Skin is vulnerable to damage and infection. Gentle skin cleansers should be used and skin moisturised daily to prevent dryness and cracking. Skin should be inspected daily and medical advice sought if there are concerns (Lymphoedema Support Network, 2022).
Compression therapy is used to reduce swelling and to prevent swelling from recurring. Arterial circulation must be checked as compression therapy must not be used if blood supply is poor (Cooper, 2013). If the limb has retained its normal shape and is not too large, compression garments can be used. If the limb has lost its normal shape or is enlarged, multilayer bandaging is required to reduce the size and restore normal shape.
Compression can be combined with manual lymphatic drainage. When the limb regains normal shape and fluid is forced out of the interstitial spaces, compression bandaging is discontinued. This is usually after 4–14 days of treatment. The person is then measured for compression garments. These may be specially made or ordered (Bianchi et al, 2012). Wrap systems can be helpful if people struggle to apply compression. These are fabric sheets made from one or more components with limited extensibility, which are applied to affected limbs and held in place with Velcro fastenings (Thomas, 2017). The person can be advised to tighten the compression system if it starts to feel loose. This improves the efficacy of compression (Damstra and Partsch, 2013).
Exercise and movement help to reduce swelling and improve independence and quality of life. Exercise improves lymphatic and vascular function and this assists in removing fluid and improves the effects of compression therapy. Exercise also improves muscle strength, assists in weight control and improves health (Rooney et, al, 2019).
Advanced therapy
Lymphoedema specialist services offer a number of advanced treatments, including low level laser therapy (LLLT), intermittent pneumatic compression, kinesiotaping, deep oscillation therapy (Hivamat), liposuction and lymphatic surgery. LLLT is reported to improve lymphatic function and reduce pain, inflammation and scar tissue (Baxter et al, 2017). Intermittent pneumatic compression (delivered using a sleeve and a pump) is normally carried out by the person with lymphoedema at home. The pressures and treatment times are set by the specialist and cannot be changed by the patient. Intermittent pneumatic compression is standard therapy in the US and has been extensively evaluated (Feldman et al, 2012).
Kinesiotaping and deep oscillation therapy can be helpful in increasing drainage (Wigg and Lee, 2014). Liposuction (the removal of fat from the affected limb) can be used in people with late stage lymphoedema who have hypertrophied adipose tissue (Lamprou et al, 2017).
Lymphatic grafting and lymph node transplantation aim to restore lymphatic function using microsurgery. Although patients who have lymphatico-venous anastomoses no longer suffer from swelling and do not need to wear compression garments, such surgery is not considered a cure (Wong and Furniss, 2020).
Discussion
Population ageing, increasing levels of obesity, inactivity and ill health in the general population are leading to increasing levels of lymphatic and venous disease. These conditions are poorly recognised by clinicians (Davies, 2019). We have insufficient services to meet increasing need (APPG on Vascular and Venous Disease, 2023). Healthcare staff require education to enable them to offer evidence-based care. As a consequence of rising demand and limited services, community nurses spend 50% of their time managing leg ulcers. In 2023, this cost the NHS £2.7 billion (APPG on Vascular and Venous Disease, 2023). In 2017–2018, community nurses cared for over 1 million people with leg ulcers, of whom 58% had a venous leg ulcer (Guest et al, 2015: 2020; 2021).
A proactive approach
People with venous and lymphatic disease can benefit from surgery and advanced treatment techniques (Davies, 2019), and encouraging and enabling people to maintain a healthy body weight, eat a healthy diet and remain active can reduce the risks of these conditions (NHS Inform, 2023: APPG Vascular and Venous Disease, 2023). However, it would be better to prevent people from developing venous and lymphatic disease in the first place.
The NHS needs to do much more to prevent disease rather than simply react to increasing ill health in the population. We also need to have improved education for clinicians and effective care pathways that support them in having patients treated.
Conclusion
NHS organisations are struggling to meet increased need for healthcare that is arising as a result of an increasingly unhealthy population and population ageing. As clinicians it is important to be aware that we can, and must, enable people to live healthier lives and to manage long-term conditions well.