Stages of Varicose Veins: From First Symptoms to Trophic Ulcer

When a patient comes to see me at M-Clinic in Tashkent, one of the first questions I hear goes something like this: «Doctor, I have varicose veins — is it serious yet?» The answer always depends on the stage. That is precisely why phlebologists around the world use the CEAP classification — a standard adopted in 1994 and updated in 2020. The letter C in this acronym stands for Clinical, and it is the classes C0–C6 that I would like to explain today in accessible language.

What the CEAP classification is and why it matters

CEAP stands for Clinical — Etiological — Anatomical — Pathophysiological. It is a multilevel system for describing chronic venous diseases. In everyday practice and in conversations with patients, however, it is the clinical component — classes C0–C6 — that is used most often. It makes it possible to:

• accurately describe the condition of the veins at the time of examination;
• compare treatment outcomes;
• choose the optimal approach — from watchful waiting to surgery.

The class is determined on the basis of a physical examination and, without exception, vein duplex ultrasound. Ultrasound reveals what the naked eye cannot see: reflux (reverse blood flow), vein diameter, and valve condition.

C0 and C1 — no varicose veins yet, but signals are already present

C0 — there are no objective signs of venous disease at all. A person may complain of fatigue and heaviness in the legs by evening, but examination and ultrasound are within normal limits. This does not mean the complaints are imagined — it simply means the cause may lie elsewhere (muscle fatigue, flat feet, hormonal changes).

C1 — telangiectasias (spider veins) or reticular veins up to 3 mm in diameter appear. Valve insufficiency at this stage is usually mild or absent. This is a cosmetic concern that is sometimes accompanied by mild discomfort. Treatment at this stage — sclerotherapy or laser coagulation of small vessels — is considered if the patient is bothered by the appearance.

C2 — the first «true» varicose veins

At this stage we already see dilated varicose veins 3 mm or more in diameter. These are tortuous vessels that protrude above the skin surface, most commonly along the inner thigh and lower leg. Complaints increase: heaviness, aching pain, nocturnal cramps, a feeling of bursting pressure.

On vein duplex ultrasound we detect reflux in the great or small saphenous vein and sometimes perforator vein incompetence. It is at this stage that delaying treatment is inadvisable: C2-class varicose veins respond well to minimally invasive techniques — endovenous laser ablation (EVLA), miniphlebectomy, or foam sclerotherapy.

The earlier treatment is started at stage C2, the lower the risk of complications and the better the cosmetic outcome.

C3 — oedema as the first warning sign

C3 — persistent oedema of the lower leg and foot joins the varicose veins, oedema that does not resolve completely even after a night's rest. This is a sign that venous hypertension is beginning to affect microcirculation and lymphatic drainage.

Patients at this stage often notice that by evening their shoes feel tight, and sock-line indentations appear. Treatment is mandatory and mirrors that used for C2, but requires more careful planning. Compression hosiery becomes not an option but a necessity.

C4 — the skin begins to suffer

The fourth class is divided into two sub-classes:

• C4a — hyperpigmentation (brown patches) and/or eczema on the lower leg. The skin is reacting to chronic venous pressure.
• C4b — lipodermatosclerosis (induration and fibrosis of the skin and subcutaneous tissue) and white atrophy — whitish scar-like areas. This is a serious signal: the skin is already irreversibly changed, and the risk of ulceration is high.
• C4c — corona phlebectatica: a fan of small dilated veins on the foot and around the ankle, added in the 2020 CEAP update as a herald of skin complications.

At this stage, treatment targets two fronts simultaneously: elimination of venous reflux (EVLA, sclerotherapy, phlebectomy) and skin restoration in collaboration with a dermatologist.

C5 and C6 — trophic ulcers

C5 — a healed trophic ulcer. A scar at the site of a former ulcer indicates that the disease has already reached a critical point. The risk of recurrence without treating the underlying cause is very high.

C6 — an open trophic ulcer. This is one of the most severe complications of varicose vein disease. The ulcer is most commonly located in the area of the medial malleolus, heals poorly, and is prone to infection.

If a non-healing wound or ulcer appears on the lower leg, especially with signs of inflammation (redness, purulent discharge, high temperature) — do not attempt self-treatment; consult a doctor as soon as possible.

Treatment of trophic ulcers is a complex undertaking: surgical elimination of reflux, local wound care, compression, and sometimes skin grafting. The outcome depends greatly on how quickly the correct treatment is started.

How the stage is determined during a consultation

During an in-person examination I assess:

1. 1Complaints and their duration.
2. 2Skin condition, presence of oedema, veins, and pigmentation.
3. 3Duplex ultrasound findings — this is the key tool without which an accurate stage cannot be determined.

The external picture is sometimes misleading: large veins may have well-functioning valves (and that would be C2), while smaller veins may produce significant reflux with already-developing skin changes (C4). For this reason, it is practically impossible to «self-diagnose a stage» from a photograph or description alone.

When to book an appointment

If you notice even one of the following signs — do not put off a visit to a phlebologist:

• heaviness and swelling in the legs that worsen by evening;
• visibly dilated veins;
• changes in the colour or texture of the skin on the lower leg;
• any non-healing wound or darkening of the skin in the ankle area.

I see patients at M-Clinic in Tashkent; home visits for patients with limited mobility can be arranged when necessary. To book a consultation with vein duplex ultrasound, please call +998 99 883-93-21 or visit phlebo.uz. The earlier we determine the stage, the more conservative treatment options will be available to us.

This article is for informational purposes only and does not replace a consultation with a qualified physician. If you are experiencing symptoms, please see a specialist.