Venous skin lesions The Phlebology Clinic / Venous insufficiency of the lower limbs / Venous skin lesions Introduction Description of the condition Risk factors Recognition and diagnosis Treatment methods Frequently asked questions Introduction Chronic venous disease (chronic venous insuffiiciency, CVI) is a common condition in which, over time, a so-called 'chronic venous insuffiiciency' develops. chronic venous insufficiency (chronic venous disease, CVD) affecting a significant proportion of the population and covering the more advanced stages of venous disease: C3 to C6. In advanced stages of venous disease, approximately 4-5% patients develop lesions (often irreversible) located in the skin and subcutaneous tissue (C4 class according to the CEAP classification), and in the 1-1.5% population they appear venous ulcerations (Class C5-C6). Skin complications of venous disease are a serious health and social problem. They negatively affect patients' quality of life, causing pain, discomfort, itching, as well as aesthetic problems that can lead to lower self-esteem and social isolation. CEAP classification (Clinical-Etiology-Anatomy-Pathophysiology) with a revision in 2020, which is the international standard for describing patients with chronic venous disease, distinguishes three subclasses of lesions within class C4:– C4a: skin discolouration or eczema;– C4b: lipodermatosclerosis (dermal-fatty sclerosis) or white atrophy (atrophie blanche);– C4c: corona phlebectatica (so-called venous rim). Corona phlebectatica - what is it? Corona phlebectatica (A malleolar flare is a cluster of tiny dilated venous vessels arranged in a fan or crown shape around the ankle - most often medial (less often lateral). These small veins dilate with the duration of the venous disease and often take on an intense bluish purple colour, which can resemble the appearance of sunbeams spreading from the centre. Venous crown (or otherwise venous rim) is a finding that used to be classified as simple dilated vascular spider veins located in the ankle region (formerly CEAP class C1). In the new edition of the CEAP, corona phlebectatica has been included in class C4 due to its association with an advanced form of chronic venous insufficiency. It is worth mentioning that patients with corona phlebectatica have 5.3 times greater risk of developing venous ulceration. This level of risk is comparable to other C4 class-specific skin lesions, such as hyperpigmentation or lipodermatosclerosis. Description of the condition Skin and subcutaneous tissue lesions (CEAP class C4) in the course of chronic venous disease are the result of complex pathological processes resulting from long-term venous hypertension in the lower limbs and progressive trophic disorders. W obrębie klasy C4 wyróżnia się kilka podtypów. Jest to już to stadium choroby żylnej, po którym występują owrzodzenia żylne goleni. Subclass C4a: hyperpigmentation (skin hyperpigmentation) - is a brownish discolouration of the skin, usually around the ankles, caused by the escape of blood (haemoglobin) and its degradation within the skin and subcutaneous tissue; on histopathological examination, the skin in these hyperpigmented areas contains both haemosiderin deposits and increased melanocyte activity. eczema venous or congestion - manifests itself as redness, itching and flaking of the skin in the affected areas; inflammation and a sensitisation reaction develop in the skin, causing eczema in the vicinity of the varicose veins. Eczematisation can also result from incorrect treatment - such as prolonged steroid administration. Subclass C4b: lipodermatosclerosis otherwise known as dermatofatty sclerosis, is a condition in which fibrosis of the skin and subcutaneous tissue occurs. Sometimes the progressive fibrosis is preceded by diffuse inflammatory oedema of the subcutaneous layer (hypodermitis). Recurrent forms of inflammation also occur. Each such episode culminates in increasing thinning of the subcutaneous tissue and deposition of further layers of fibrosis. Lipodermatosclerosis can be a warning sign of impending ulceration. white atrophy (atrophie blanche) is a symptom of advanced venous insufficiency; white, scar-like patches appear on the skin surrounded by dilated capillaries. In white atrophy, congestive tissue damage and chronic inflammation lead to the development of fibrosis, an excessive deposition of collagen fibres. Fibrosis stiffens the tissues and reduces their elasticity, further impeding the healing of wounds, which are made quite easily in this clinical condition. Subclass C4c: corona phlebectatica is a fan-shaped pattern of numerous small intramedullary veins on the medial or lateral side of the ankle and foot. Corona phlebectatica was first described in 1960 by Van der Molen. The lesions in this location consist of four main components: – blue - often extensive - telangiectasias, i.e. dilated intradermal veins resembling the fan-shaped branches of a tree; – red telangiectasias - smaller than the blue ones; these are very superficially located small vessels;– „venous cups" - small punctuate venous dilatations usually 6-8 in number, these extend into the soleus arch of the foot; they arise as a result of dilatation of the triangular venous drainage originating from the soleus arch;- congestive spots: circular, purple areas formed by capillaries just below the epidermis. UIP (Union Internationale de Phlébologie) proposed a rather simple classification of corona phlebectatica lesions. It distinguishes between three stages of the disease. Grade I - corona marginalis are single telangiectasias or small reticular veins (reticular veins) arranged in the form of a periosteal rim. Grade II - The corona median is a well-defined rim formed by telangiectasias and reticular veins. Grade III - corona maxima - this is a widespread form; a rim of telangiectasia and reticular veins, often accompanied by skin trophic changes, considered an early sign of advanced venous disease and a significantly increased risk of developing venous ulceration of the shin. In case-control studies, the risk of venous ulceration in patients with corona phlebectatica is similar to that found in those with venous eczema (C4a) and lipodermatosclerosis (C4b). Therefore, people with this complication of venous insufficiency are now classified into subcategories: C4c. In patients with chronic venous insufficiency is quite common lymphatic microangiopathywhich causes damage to lymphatic capillaries, increased permeability of their walls and secondary skin complications. Proteins leaking into the surrounding tissues in excess exacerbate oedema and inflammation. This accelerates tissue fibrosis, which in turn exacerbates the symptoms of venous insufficiency. Chronic lymphatic stasis in patients with advanced forms of chronic venous insufficiency leads to bacterial lymphangitis (dermatolyphangitis) and cutaneous papillomatosis. Recent scientific studies on the function of the lymphatic system in patients with chronic venous disease show that lymphatic outflow is already impaired at grades C2 and C3. Risk factors for skin lesions (C4a-C4c) genetic predisposition - Genetic predisposition plays a key role in the development of venous disease and its complications, including skin lesions. venous hypertension - This is the primary factor in the development of skin lesions in the course of venous disease. Long-term venous hypertension in the lower limbs damages the blood vessels, increases their permeability and leads to fluid exudation into the tissues. venous valve insufficiency - Their dysfunction exacerbates venous hypertension and promotes more rapid formation of skin lesions. chronic inflammation - Venous hypertension and tissue hypoxia activate the immune system, leading to an influx of leukocytes and the release of inflammatory mediators. These damage the endothelium of blood vessels and surrounding tissues, contributing to the development of skin lesions. concomitant lymph stasis - Progressive lymphatic insufficiency is already observed in the early stages of venous disease. This exacerbates swelling, impedes wound healing and promotes the development of skin lesions. age - The risk of developing venous disease and skin lesions increases with age. lifestyle - Standing or sitting for long periods of time, lack of physical activity, wearing tight clothing - these are factors that impede blood flow in the veins and promote the development of venous disease. changes hormonal - intense hormonal deviations and fluctuations, e.g. during pregnancy, can exacerbate the symptoms of venous disease and favour the development of skin lesions. obesity - Excessive body weight increases the strain on the venous and lymphatic systems, which promotes the development of venous disease and skin lesions. Obesity is one of the more common causes of venous disease progression and the occurrence of typical skin lesions on the legs secondary to long-term venous insufficiency. Mechanism of skin lesions in venous insufficiency CEAP class C4 skin lesions are a manifestation of advanced venous disease and their development is the result of complex pathological processes happening at the microvascular level.Venous hypertension in the lower limbs is a fundamental factor in the pathogenesis of skin lesions in venous disease. It is caused by overloading of the venous bed or disturbances of venous blood outflow in the large vascular axons (e.g. in the course of venous compression phenomena or post-thrombotic palpation). Venous valve insufficiency usually arises secondary to these processes and phenomena. Long-term venous hypertension damages the blood vessels, increasing their permeability and leading to fluid exudation into the surrounding tissues. The congestion, oedema and microcirculatory disturbances in the subcutaneous tissue and skin lead to their hypoxia and and tissue malnutrition, which promotes the development of skin lesions (the so-called 'skin lesions'). trophic changes). Chronic tissue hypoxia and vascular endothelial damage activate the immune system. This leads to an influx of leukocytes and the release of inflammatory mediators. Chronic inflammation ultimately results in fibrosis of the subcutaneous tissue and significant thinning of the skin. At this stage of venous disease (C4a, C4b, C4c), patients are already one step away from the most serious complication of venous disease - the venous ulceration shinsclassified as C5 (healed venous ulceration) and C6 (active venous ulceration). Recognition and diagnosis The routine diagnosis and diagnosis of skin lesions (CEAP class C4) in venous insufficiency includes the basic elements of phlebological management.It should always start with a detailed medical history (including co-morbidities, history of treatment for venous insufficiency or past venous thromboses) and a physical examination. It is particularly important to assess the patient in a standing position, assess the cohesiveness of the oedema and examine the peripheral pulse. Patients with chronic venous insufficiency in grades C4 to C6 must undergo a detailed assessment of skin lesions. In the diagnostic evaluation, Doppler ultrasonography is the test of choice. Standing and lying assessments always include: superficial venous system, deep venous system, venous patency, evaluation of venous valves with detailed analysis of reflux entry and exit. Patients who have developed advanced trophic changes are usually among the more difficult cases diagnostically and therapeutically. In these patients, it is always necessary to assess the degree of pelvic venous insufficiency and exclude venous outflow disorders at the level of the iliac-caval axis (more often left). In selected cases, the phlebologist will reach for additional tests, such as blood tests, assessment of the ankle-brachial index (ABI), plethysmography or capillorscopy. In cases that are more difficult to diagnose and in which treatment is planned pelvic venous insufficiency we reach for computed tomography venography (CTV), magnetic resonance contrast venography (MRV) and digital phlebography. The latter imaging modality is usually used during the treatment phase itself. Intravascular ultrasound (IVUS) is an unhelpful and rather expensive option in the routine diagnosis of patients with skin lesions in the course of advanced venous disease. "Doppler ultrasound of the abdominal and small pelvic veins is a necessary test to perform in patients with skin lesions in the course of venous insufficiency". dr n. med. Cezary Szary The following should also be borne in mind differential diagnosis of skin lesions. It should take into account other disease entities that may mimic skin lesions characteristic of C4. These include subcutaneous tissue inflammation, systemic scleroderma or autoimmune disease lesions. In the case of patients with C4b (lipodermatosclerosis and white atrophy) It is crucial to assess the risk of progression to stage C5/C6 (venous ulceration), particularly in areas of sclerosis and skin discolouration. Treatment methods Chronic venous disease is a condition that develops gradually and requires a systematic, comprehensive approach to treatment. When the first discolourations, redness, varicose veins or induration perceptible in the subcutaneous tissue or skin appear on the legs, it means that the disease has entered the C4 stage. This is the point at which proper treatment becomes particularly important to prevent the development of more serious complications, such as venous ulcers of the shin. Skin lesions in chronic venous disease are not just a cosmetic defect - they are a clear warning sign. They arise as a result of prolonged stagnation of excess venous blood and are like a warning sign. Fortunately, we now have effective treatments that, when used systematically, can significantly improve the condition of the skin and alleviate the symptoms of venous disease. Treatment must be comprehensive and be carried out over a long period of time, as skin changes that have developed over months or years will not disappear after a few days or weeks of treatment. The primary treatment for venous insufficiency at this stage is appropriately selected compression therapy. It is advisable to wear compression products (knee socks, stockings or bandages) with a compression strength of CCL2 or CCL3 every day. Patients with this type of problem need to take good care of their skin. Care for it with gentle cleansers. Drying of the skin must be done without rubbing. Moisturising creams containing as few allergenic ingredients as possible are used. Phlebotropic medications usually have an adjunctive role to the compression therapy used. Well-targeted physical activity (e.g. calf muscle strengthening exercises and regular walking) is important, as is maintaining a healthy body weight and adequate hydration. Most patients at this stage require surgical treatment, which should always be individualised and as minimally invasive as possible. Currently, non-surgical management is preferred in patients at stage C4. Mostlyquestions asked Can trophic changes on the skin of the legs from varicose veins occur at a young age? Although chronic venous insufficiency and associated skin lesions (C4) are more common in middle-aged and elderly people, they can also occur in younger patients. It all depends on the background of the venous insufficiency and how long it has been present. In patients who are younger, but with co-occurring risk factors such as genetic predisposition, sedentary lifestyle or obesity, such changes can occur at an early age. Early detection and treatment of venous insufficiency at an early age can prevent complications and the development of skin lesions. Can skin lesions in chronic venous insufficiency be painful? Skin lesions resulting from chronic venous insufficiency (C4) can be painful, especially when accompanied by inflammation or oedema. Lipodermatosclerosis (C4b) is a typical condition of advanced venous insufficiency, which can progress with exacerbations. Painful swelling and inflammation then occur. After several such episodes, fibrosis of the subcutaneous tissue and thinning of the skin occurs. It becomes tight and thin like parchment paper. This causes a feeling of stiffness and pain in the area affected by the sclerosis. In the case of lesions eczematous, eczematous (C4a), Patients often experience itching, burning or even acute pain, especially if bacterial superinfection occurs. Can skin lesions in chronic venous insufficiency lead to ulceration? Yes, in advanced stages of chronic venous insufficiency, if appropriate treatment is not implemented, skin lesions can lead to venous ulcers of the shin. These usually form at the level of the C1-C2 perforators at or just above the medial ankle. This is the result of chronic inflammation and venous hypertension, which cause damage to the skin and subcutaneous tissue. Venous ulcers of the shin, especially in patients with advanced post-thrombotic syndrome, are difficult to treat and require a comprehensive approach, which is why it is so important to prevent their formation through early treatment of venous insufficiency of the lower limbs. How common are skin lesions in patients with venous disease? In whom do they occur most frequently? Venous insufficiency lesions visible on the skin, corresponding to stage C4 according to the CEAP classification, occur in approx. 5-7% adult population. The incidence increases significantly with age. It is estimated that in people after the age of 65 they may even occur in 10-12% people. In the case of stage C4, there is not as clear a female predominance as in the case of varicose veins (C2) or spider veins (C1). The prevalence is only: 1.2-1.5 to 1.0. In one in four with C4-type lesions progress to C5 or C6 within 5 years, i.e. the development of a venous ulceration of the shin. This is why it is so important to reduce risk factors and seek appropriate treatment from a phlebologist. You can read about particularly high-risk groups below.Groups at particular risk of developing skin lesions in chronic venous insufficiency are: those performing long hours of standing or sitting work; following a history of deep vein thrombosis (DVT); with marked obesity (BMI >30); women after multiple pregnancies (multiple births); with a family history of advanced venous insufficiency, including venous ulcers of the shin (C5-C6); with venous valve insufficiency lasting for more than 10 years. What tests are recommended to diagnose skin lesions in a patient with varicose veins on the legs? Doppler ultrasound of the veins of the lower limbs, pelvis and abdominal cavity is always the basis of diagnosis. It allows the blood flow in the veins to be assessed and the sites of reflux and its cause to be identified. In some cases, the doctor may also recommend additional tests such as phlebography or computed tomography (CT) or magnetic resonance (MR) imaging. These examinations make it possible to pinpoint the cause of the problem and tailor an individualised treatment plan. Related issues 01 / Venous insufficiency of the lower limbs 02 / Venous ulcers of the shin 03 / Varicose veins of the lower limbs Modern vein treatment We offer treatment both on an outpatient basis and in day ward admissions. The stay is of short duration. The patient spends between 1 and 5 hours in the Clinic. Make an appointment
