Varicose veins, also known as varices or varicosities, are bulging, twisted veins that usually appear in the legs and are a form of chronic venous disease. Clinically, a varicose vein is defined as a dilated vein 3 mm in diameter or larger, as measured in the upright (standing) position.^[1] The two veins most commonly affected are the greater saphenous vein and the small saphenous vein, both of which are found in the leg; varicose veins in other parts of the body, such as the pelvis, are less common. Varicosities can occur in one or several veins and may change in size or appearance over time. They may cause discomfort, but serious complications are rare. Without treatment, they do not go away.

While the appearance of varicose veins can be cosmetically concerning, they rarely cause serious complications and may even be asymptomatic. When symptoms do occur, the most common are aching, tightness, burning, itching, tingling, throbbing, tenderness, and swelling in the legs. These symptoms are often worse at the end of the day, especially after prolonged sitting or standing, and may resolve with leg elevation. Restlessness, heaviness in the legs, and nocturnal leg cramps are also symptoms of varicose veins. Less common but more serious complications can include vein infections and blood clots.^[2][3]

Varicose veins are diagnosed by consideration of symptoms (when present) in combination with a physical examination to identify the presence, location, and severity of varicose veins. The exam may be done in a standing position to better assess venous dilation, and often includes checking pulses and looking for skin changes. In some cases (especially symptomatic ones), an imaging test called a duplex venous ultrasound may be completed to more closely evaluate the veins. An ultrasound can determine how well blood is flowing through the veins and where there may be improperly working valves that are causing blood to flow backwards (called venous reflux). This test is painless and noninvasive. Varicose veins are clinically classified using the class, etiology, anatomy, and pathophysiology (CEAP) system, which ranks the presence and severity of chronic venous disorders on a continuum from no venous disease to active venous ulcers.^[1]

Medical treatments vary depending on the severity of the condition and patient preferences. People without symptoms or cosmetic concerns may not require any treatment. Mild to moderate cases may respond to conservative management, which includes using compression stockings (or socks) and certain lifestyle modifications, like avoiding prolonged standing or straining, performing exercise, wearing nonrestrictive clothing, reducing cardiovascular disease risk factors, losing weight, and elevating the affected leg(s). The goal of these strategies is threefold: to improve blood flow in the veins and prevent blood from pooling; to reduce venous swelling and inflammation; and to compress dilated veins. While conservative management may reduce symptoms, it usually does not drastically change the appearance of the veins. For example, a 2021 systematic review on the use of compression stockings as a first-line treatment for varicose veins found that stockings improved symptoms but did not reduce the progression or recurrence of the disease.^[4]

There are some medications that can help people with varicose veins. Diosmiplex (Vasculera) is a medical food derived from orange rinds and is used in the treatment of varicose veins. Topical steroid creams or ointments may be used to treat rashes that are secondary to varicose veins.

People with persistent symptoms, severe complications, or cosmetic concerns may opt for interventional treatments, like thermal ablation (endovenous or radiofrequency ablation), sclerotherapy, and surgery to remove affected veins. While each of these is effective, thermal ablation and sclerotherapy are less invasive and may be initially preferred over other surgical procedures.^[5]

Phlebotonics are broadly characterized as a group of venoactive compounds that are used to treat varicose veins and other chronic venous disorders. They include natural flavonoids extracted from plants and synthetic compounds with flavonoid-like properties. Many work by increasing venous tone, decreasing the permeability of capillaries, fighting inflammation, improving lymphatic drainage, or making blood less viscous. Some examples are aminaftone, calcium dobesilate, Gotu Kola (Centella asiatica), diosmin, hidrosmin, French pine bark extract (Pycnogenol), grape seed extract, and rutosides. A systematic review from 2020 concluded that there was low to moderate-certainty evidence that phlebotonics may reduce edema, pain, cramps, restless legs, and lower-leg swelling.^[6] The evidence for most phlebotonics is limited, but horse chestnut seed extract^[7] and French pine bark extract^[8] are two phlebotonics that may be effective for treating signs and symptoms of varicose veins.

The direct effect of diet on varicose veins has been insufficiently studied. A Mendelian randomization study concluded that higher genetically-predicted iron levels were associated with an increased risk of varicose veins, while calcium, magnesium, and zinc were inversely associated with varicose vein risk. The risk for varicose veins was increased with higher alcohol consumption and decreased with higher coffee consumption.^[9] The following dietary patterns have been reported among patients with venous leg ulcers: Lower intakes of omega-3 fatty acids, vitamins A and D, and zinc; a higher omega-3:omega-6 ratio; an excessive intake of sodium, saturated fat, and sugar; and an inadequate intake of fruits and vegetables.^[10][11] While a diet low in fiber and high in refined carbohydrates has been linked to the risk of varicose veins, this relationship is not well-established.^[12][13]

There is data to support the effectiveness of a variety of exercise programs in improving both the function of varicose veins and overall quality of life. Exercise improves endothelial function and circulation in people with varicose veins, even when physical activity levels are initially low and exercise capacity is reduced.^[14] Indeed, structured exercise training improves calf muscle pump function in people with varicose veins (chronic venous insufficiency).^[15] Balneotherapy and aquatic exercise also improve quality of life, pain, edema, and functional parameters (i.e., venous function) among varicose vein patients.^[16][17] For post-surgical varicose vein patients, treadmill exercise improves microvascular endothelial function,^[18][19] although therapeutic exercise (i.e., stretching, ankle-strengthening exercises, foot and ankle flexion/extension) may not improve quality of life in this population.^[20]

Because overweight and obesity are associated with an elevated risk for varicose veins, people with these conditions may experience a reduction in symptoms with weight loss.^{[21][22][23][24]} However, there are no studies directly investigating the effect of weight loss on quality of life, symptoms, or functional measures among people with varicose veins. Avoiding prolonged standing and reducing cardiovascular disease risk factors, such as high blood pressure, may also reduce varicose vein symptoms.^[2]

Varicose veins are caused by a combination of genetic and environmental factors that ultimately lead to venous dysfunction. Normally, healthy veins return blood to the heart with the help of skeletal muscle pumps (which are activated during muscle contraction) and one-way valves (which prevent blood from flowing backward).^[25]

In people with varicose veins, these mechanisms do not work properly, often due to high blood pressure, insufficient one-way valve function, or structural/functional changes to the walls of the veins. Consequently, blood begins to flow backwards (venous reflux), increasing venous blood pressure. Over time, this leads to weaker blood vessel walls, dilated (stretched) blood vessels, and dysfunctional one-way valves. The result is the appearance of large, discolored, and twisting veins in the lower extremities.

High blood pressure and altered blood flow patterns in the veins also elevate levels of inflammatory cytokines, lymphocytes, neutrophils, monocytes, macrophages, and other growth factors, which further contribute to venous remodeling and structural damage.^[26] All of these processes are enhanced in the presence of risk factors, such as obesity, pregnancy, tall height, a family history of varicose veins, age, smoking, and occupations that require prolonged standing or sitting.^[26]