When the valves fail in some of the veins in the legs, blood falls down the veins causing inflammation at the lower legs and also rapid increases of pressure on standing. As we saw in CEAP C3 disease, this can start to cause damage outside of the vein itself in the surrounding tissues. In CEAP C3 disease, this is just oedema, collection of fluid.
When this damage and inflammation gets worse, the inflammation can work its way right the way through the tissue under the skin and the skin of the ankle can start to become affected. When skin becomes damaged due to inflammation, it can show a variety of changes. This can be a redness, a shiny tight and hard patch, a brown area or a patch of eczema which is both itchy and red. These different forms of skin damage have different names including lipodermatosclerosis (or LDS) for the harder shiny patches that are often discoloured, venous eczema for the red itchy patches of eczema and haemosiderin deposition for the dark brown patches.
All of these forms of skin damage can be seen at the ankle if the damage from blood falling the wrong way down the veins in patients with varicose veins and “hidden varicose veins” is severe enough.
In CEAP C4 disease, the skin damage almost always occurs on the inner aspect of the lower leg, often just above the ankle bone and below the calf muscle (the area called the “gaiter area”). However, the skin damage can also be found around the ankle bone, just behind the ankle bone, under the ankle bone or less commonly on the outer aspect of the lower leg or directly over the varicose veins themselves.
As the CEAP C4 classification is a clinical score, then really you should see the typical skin damage and also visible varicose veins on standing. However, as we discussed in CEAP C3, if there are classic changes of the skin indicating venous skin damage, and varicose veins are not visible on the surface but “hidden varicose veins” are suspected as the source of the venous reflux, then it is appropriate to call the condition CEAP C4, provided a venous duplex ultrasound scan is performed to confirm that there are “hidden varicose veins” causing the venous reflux that is damaging the skin.
In the majority of patients with CEAP C4 skin damage of the lower legs, the underlying cause is venous reflux in the veins causing varicose veins or “hidden varicose veins” in addition to the skin damage. This can be due to reflux in the great saphenous vein, small saphenous vein, incompetent perforators or less commonly the anterior accessory saphenous vein and rarely the pelvic veins. Pelvic venous reflux causing varicose veins arising from the pelvic veins rarely causes CEAP C4 skin damage but interestingly in 2013, we performed vein surgery on such a patient for a TV programme. Treating her pelvic venous reflux completely cured her varicose veins and also a CEAP C4 skin damage, returning the skin to normal over many months.
Although superficial venous reflux is usually the cause of CEAP C4 skin damage, it is also found in patients with more severe venous disease such as post thrombotic syndrome (PTS) – a condition caused by damage to the deep veins following severe or multiple deep vein thromboses (DVTs). In this condition, when the deep veins are involved, it is far harder to get a cure although a cure still may be possible. With the latest imaging techniques and treatments, the majority of people with CEAP C4 disease should expect to be totally cured.
However, the underlying cause of the CEAP C4 skin damage cannot be found without venous duplex ultrasonography of the superficial and deep systems. Because of the complexity of the examination that is required, this requires the skills of specialised vascular scientists who are able to scan the deep and superficial veins with confidence because they do this every day. Quick scans performed by doctors or other personnel who have other duties, in addition to duplex ultrasound scanning are unlikely to have the practice and skills to get the required level of diagnosis to ensure the correct treatment strategy is followed.
In the past and sadly even today, many doctors and nurses who see CEAP C4 skin damage around the ankles and lower legs, tell patients that they are “incurable”. Such patients are often told that their only hope is to wear graduated compression stockings or surgical support stockings every day whenever they are up.
Unfortunately, patients often believe this and do not seek a cure.
Fortunately, for those patients who keep searching for better treatments, modern techniques of imaging and treatment mean that we are now able to cure most patients with CEAP C4 skin damage.
If you have skin damage around the ankles typical of CEAP C4, it is essential that you have an expert venous duplex ultrasound scan to find out the underlying cause of the skin damage. It is no longer acceptable to be given any creams or steroid gels, or to be told just to wear graduated compression stockings or surgical support stockings. These “treatments” that have been traditionally prescribed have no effect at all on the underlying problem and therefore are not treatments at all. They are merely ways that patients have been refused proper investigation and treatment in the past.
The National Institute of Health and Clinical Excellence (NICE) has made it very clear that anyone who has CEAP C4, in other words any skin damage due to varicose veins for “hidden varicose veins”, must be referred to a vascular service for a venous duplex ultrasound scan and assessment for treatment of their vein problems by endovenous surgery. The Whiteley Clinic satisfy the NICE criteria for such a vascular service as it has a multidisciplinary team performing the scans and the treatments. A single doctor performing their own scans and recommended treatment do not satisfy these criteria and do not qualify as a “vascular service” to investigate and treat varicose veins as defined by NICE CG 168
When you have a specialised venous duplex ultrasound scan performed by one of the specialist vascular scientists at The Whiteley Clinic, they will check your deep veins, your superficial venous trunks (great saphenous vein, small saphenous vein and anterior accessory saphenous vein), your perforating veins and if required, your pelvic veins. They will also look for other less well-known causes of venous reflux such as the Giacomini vein.
Once a pattern has been built up, a report is written for you to take to The Whiteley Clinic specialist consultant, trained in treatment through The Whiteley Protocol®. Using the research performed at The Whiteley Clinic, we are able to choose the optimal combination of treatments for your specific vein pattern. Where as many cheap vein units or individual doctors recommend (standard) treatments and offer standard prices, our research has shown that every patient has individual patterns. Therefore to get excellent treatment, they have to be tailored to each individual case on the principles of The Whiteley Protocol®.
It is very rare that we are unable to improve or cure patients with CEAP C4 disease. Patients should no longer accept being consigned to support stockings for the rest of their lives unless they are sure that they have been fully investigated using techniques and specialists who can identify the least common conditions.
Failure to treat the CEAP C4 often leads to venous leg ulceration. Therefore treatment of CEAP C4 prevents progression to leg ulcers in the majority of cases.