How should varicose veins be treated?

The varicose veins are swollen, dilated and tortuous, occurring predominantly in the legs due to faulty valves that impede blood flow. Although they are common and can affect both men and women, their prevalence increases with age. The good news is that modern varicose vein treatments are effective, minimally invasive and underpinned by clinical research.

Depending on the severity, treatments range from compression stockings to advanced medical procedures for varicose veins, such as sclerotherapy, laser ablation or radiofrequency ablation. Each approach aims to restore proper circulation, relieve discomfort and improve cosmetic appearance. The choice of treatment depends on several factors, including the size and location of the affected veins, the severity of symptoms, the presence of complications such as ulcers and the patient’s overall health. A vein specialist typically performs an ultrasound scan to determine the most effective and least invasive approach for achieving lasting results.

The initial approach to managing varicose veins typically centres on non-invasive measures aimed at improving blood circulation and alleviating symptoms.

Compression stockings and support socks for varicose veins.

Compression stockings, or elastic hosiery for varicose veins, are regarded as an effective first-line non-surgical treatment option. These elastic stockings apply the greatest pressure at the ankle, with progressively lower pressure up the leg. This pressure gradient compresses the superficial veins, increases blood flow towards the heart and reduces venous reflux. Consequently, it prevents blood stasis in the veins and helps alleviate the sensation of heaviness, pain and oedema.

Compression stockings are categorised into different categories based on the pressure exerted by the garment at the ankle.

Several research studies have suggested that medical compression stockings significantly improved symptoms. A randomised, controlled trial followed 50 patients with uncomplicated varicose veins over four weeks, comparing class I compression stockings (18–21 mmHg) with no treatment. Participants wearing these stockings showed a significant reduction in overall symptoms, pain, heaviness and swelling, whereas the control group showed no improvement and even experienced increased pain. In another double-blind, placebo-controlled trial, below-knee graduated compression stockings (18–21 mmHg) were tested in 30 patients suffering from painful varicose veins over a one-week period. The compression group revealed a significantly greater reduction in pain, as well as trends towards decreased swelling and discomfort compared to the placebo stockings.

In general, compression stockings are regarded as safe and well tolerated, but if they are not fitted correctly, they can sometimes cause skin irritation, pressure injuries and ulcers. In the event of adverse effects, the first step is to discontinue wearing the stockings temporarily and assess the condition of the skin. These problems usually occur when the compression level is too high, the size is unsuitable or the stocking has folds that exert excessive pressure on the skin. The patient should then consult a healthcare professional to verify the fit, size and compression class, and to rule out any underlying pathology such as arterial disease or dermatological sensitivity.

Compression stockings are contraindicated in patients with active skin infections, severe arterial disease or uncontrolled cardiac conditions. When correctly sized and prescribed, they are generally safe and can also help relieve the symptoms of varicose veins during pregnancy, provided there are no contraindications.

Compression stockings constitute a simple, non-invasive method to relieve symptoms and slow the progression of varicose veins, but they do not eliminate existing veins and often need to be worn in the long term.

Exercises for varicose veins.

Although exercise does not eliminate existing varicose veins, it plays a crucial role in the management and relief of symptoms by reducing venous pressure and strengthening the calf muscle pump. Simple and healthy habits such as daily walking, cycling, yoga, leg elevation and lower-limb strengthening exercises improve blood circulation, lower venous pressure and relieve swelling as well as the sensation of heaviness. An eight-week comparative trial involving 30 women with varicose veins showed that both aerobic and dry-land exercises reduced pain and improved quality of life, with the greatest benefit observed for dry-land exercises. These findings support structured physical activity as a valuable adjunctive approach to symptom management.

However, certain sports are not suitable for individuals with frequent or symptomatic varicose veins. High-impact activities or exercises involving intense exertion, such as heavy weightlifting or running, can elevate abdominal and leg pressure. This often occurs because individuals inadvertently perform a Valsalva manoeuvre, meaning they hold their breath and tense their muscles during effort. This apnoea combined with muscle contraction increases venous pressure and can aggravate symptoms. Therefore, people with varicose veins are generally advised to opt for low-to-moderate-impact activities that promote calf muscle pumping.

Lymphatic drainage.

The lymphatic drainage manual is often employed as an adjunctive approach to alleviate leg swelling and heaviness associated with varicose veins. Although it does not treat the underlying venous reflux, when performed by a trained professional, this technique stimulates lymphatic circulation, reduces fluid accumulation in the lower limbs and alleviates discomfort after prolonged standing. A randomised study involving 70 patients with chronic venous disease found that two weeks of preoperative lymphatic drainage partially reduced leg volume by 4.2% and improved quality of life compared with no preoperative drainage. Both groups improved postoperatively, but the drainage group experienced greater symptom relief and better overall functional outcomes.

Creams and ointments for varicose veins.

Topical creams and ointments intended for varicose veins alleviate symptoms such as heaviness, warmth and slight oedema, but they cannot strengthen the venous wall or reverse the development of varicose veins. These products often contain plant-derived active ingredients such as escin (horse chestnut), the Centella asiatica, witch hazel or flavonoid-rich extracts. Some clinical studies suggest that escin-based gels can reduce leg volume and discomfort when applied regularly, particularly in cases of early venous insufficiency.

A pilot study involving 32 adults with chronic venous disease evaluated a topical cream containing 10% witch hazel, 2% horse chestnut extract and 2% rutin, applied at home for six weeks. Baseline and follow-up assessments demonstrated a excellent participant adherence and an improvement in the Venous Clinical Severity Score. These preliminary findings suggest that herbal-based topical formulations could help reduce the clinical symptoms of varicose veins. However, these effects remain modest and are concentration-dependent.

Current research data do not provide robust or consistent conclusions regarding the long-term efficacy of topical treatments, and their benefits appear to be primarily symptomatic rather than curative.

Dietary supplements for varicose veins.

Several venoactive agents are used to alleviate the symptoms of varicose veins and chronic venous insufficiency, but they differ in their regulatory status and the strength of the evidence. Diosmin–hesperidin combinations (often at a dose of 450 mg/50 mg per day) are the most extensively studied venoactive agents and have been shown to reduce sensations of leg heaviness, oedema and cramps in chronic venous insufficiency. This combination reinforces venous tone by promoting contraction of the smooth muscle in the venous wall, which reduces venous distension and improves venous return.

Other oral herbal supplements are also used to support venous health, with varying levels of evidence. Horse chestnut seed extract (standardised to 50–150 mg of aescin per day) has demonstrated improvements in oedema and pain in several clinical trials. This extract is rich in aescin, a compound that reduces capillary permeability and stabilises endothelial function, thereby limiting fluid leakage and oedema. Moreover, aescin and flavonoid-rich extracts exert anti-inflammatory effects by reducing leucocyte activation and endothelial inflammation, which alleviates venous hypertension and tissue damage. Another extract from French maritime pine bark has also shown a reduction in leg swelling and capillary leakage in small-scale studies. This extract decreases capillary leakage and limits oedema. Furthermore, it improves microcirculation by increasing the deformability of red blood cells and reducing platelet aggregation, promoting smoother blood flow and better tissue oxygenation.

Ginkgo biloba is a widely used plant extract with antioxidant, anti-inflammatory and microcirculatory effects. Experimental studies suggest it can protect endothelial cells, reduce platelet activation factor and improve haemorheological properties, which is relevant in chronic venous insufficiency. However, clinical data on the use of Ginkgo biloba alone in varicose veins remain limited. Most of the favourable evidence comes from venotonic combinations pairing Ginkgo biloba with agents such as troxerutin and heptaminol, which have demonstrated improvements in pain, heaviness, cramps and leg oedema when used alongside compression measures and lifestyle modifications. Because Ginkgo may modulate platelet function, it should be used with caution in individuals on anticoagulants, those with bleeding disorders or before surgery, and medical advice is recommended prior to its use.

Although food supplements alleviate symptoms, they do not eliminate varicose veins and should be used as an adjunct therapy under medical supervision.

When conservative measures such as compression therapy and lifestyle modifications prove insufficient to alleviate symptoms or slow the progression of varicose veins, minimally invasive procedures are often considered as the next step in their management.

Sclerotherapy for varicose veins.

Sclerotherapy is one of the most commonly used non-surgical treatments for varicose veins and has been practised in its modern form since the 1940s. The procedure consists in injecting a liquid or foam sclerosant, most often polidocanol or sodium tetradecyl sulphate, directly into the affected vein. These agents disrupt the venous endothelium, causing the vessel walls to collapse, become occluded and gradually transform into a fibrous cord reabsorbed by the body. Blood flow is then diverted to healthier veins.

Although sclerotherapy effectively improves symptoms and the appearance of visible veins, it does not correct the underlying issue of venous reflux or valvular weakness. Consequently, neighbouring superficial veins may dilate over time and recurrence is possible even after successful treatment. A 2021 Cochrane review of 28 clinical trials involving more than 4,200 patients demonstrated that sclerotherapy improves aesthetic outcomes, quality of life and reduces residual veins compared with placebo. However, recurrence rates could not be precisely quantified due to variations in follow-up duration and in definitions of evaluation criteria. Long-term studies confirm that repeat sessions or additional treatments are often necessary.

The side effects associated with sclerotherapy are generally mild and transient, such as bruising, itching or skin discolouration, while rare complications can include superficial thrombophlebitis or, very rarely, deep vein thrombosis. Sclerotherapy is contraindicated in pregnancy, acute deep vein thrombosis, severe peripheral arterial disease, known allergy to sclerosing agents, and in situations where mobility is limited.

Although sclerotherapy effectively closes the treated vein, it does not cure the underlying chronic venous insufficiency; hence recurrence may occur even after successful treatment.

Laser therapy for varicose veins.

Endovenous laser ablation (EVLA) is a minimally invasive procedure used to treat varicose veins by delivering laser energy into the dilated vein, causing it to collapse and close. A fine catheter is inserted into the vein under local anaesthetic, and a laser fibre is then introduced. When activated, the laser delivers controlled thermal energy along the vein wall, causing it to contract, collapse and seal. Blood is then naturally redirected to healthy veins. Typically, the procedure takes 30 to 45 minutes and is performed on a single vein per session. Patients with multiple varicose veins require several sessions.

According to a meta-analysis, varicose vein ablation achieves a success rate of approximately 94.5%, with recurrence in 10.3% and recanalisation in 3.6% of treated veins. The most frequent side effects after EVLA are mild and transient, such as cutaneous bruising, pain, oedema or induration along the treated vein. In rare instances, more serious complications, such as deep vein thrombosis (0.6%) or pulmonary embolism (0.4%), may arise, but they remain uncommon when the procedure is correctly performed.

EVLA is regarded as an effective and safer alternative to open surgery, often resulting in faster recovery and fewer side effects.

Radiofrequency ablation for the treatment of varicose veins.

Radiofrequency ablation of varicose veins is a modern, minimally invasive procedure performed using controlled thermal energy to obliterate damaged or dilated veins. A fine catheter is inserted into the affected vein, and radiofrequency energy is applied to the vein wall, causing it to contract, close and eventually be reabsorbed by the body. Once occluded, blood flow naturally diverts to healthy veins, improving circulation and reducing both visible swelling and discomfort. Most patients require only a single session per vein, although additional sessions may be necessary if several veins are affected.

Among all varicose vein treatment options, radiofrequency ablation (RFA) has become the method of choice, as it is less painful, safer and allows quicker recovery. Studies have shown that it yields results that are at least as effective, if not superior, to older techniques such as endovenous laser ablation (EVLA) and open surgery. According to several clinical reviews, RFA achieves a success rate exceeding 90% of venous closure and significantly reduces post-treatment pain, bruising and nerve irritation compared with laser procedures. Common temporary side effects include bruising, swelling, a feeling of tightness or mild skin numbness. This method is contraindicated in cases of pregnancy, active deep vein thrombosis, superficial vein thrombosis, severe peripheral arterial disease, local skin infection at the access site, allergy to anaesthetic agents and any condition preventing early mobilisation after the procedure.

Recent studies comparing radiofrequency ablation (RFA) with endovenous laser ablation (EVLA) have shown that patients treated with RFA experience lower pain levels, require fewer painkillers and suffer less bruising and skin burns. Thus, RFA combines excellent aesthetic outcomes with lasting relief from symptoms such as heaviness, swelling and discomfort..

Surgical treatments for varicose veins.

When addressing varicose vein correction, surgical treatment is considered a traditional option, generally reserved for cases where less invasive techniques, such as radiofrequency or laser ablation, are unsuitable or have not been effective. The aim of surgery is to remove or ligate the damaged veins to restore healthy blood flow. Common procedures include ligation (closure of the affected vein at its origin), vein stripping (removal of a long segment of the great saphenous vein, typically extending to the knee), and ambulatory phlebectomy (excision of small superficial veins through tiny skin incisions). Modern techniques often employ inversion extractors and vein hooks, reducing tissue trauma and enhancing cosmetic outcomes.

Recent research has shown that varicose vein surgery, including stripping and phlebectomy, remains safe and effective even in elderly patients. A comprehensive American database study of over 48,000 patients revealed a very low complication rate of approximately 2.5% and an extremely low mortality rate (0.02%), even among those aged 80 and above. The results also indicated a growing number of older patients undergoing these interventions, often for more advanced conditions such as venous ulcers. This study confirmed that age alone does not constitute a risk factor for unfavourable outcomes. However, patients with comorbidities such as renal insufficiency or pre-existing open wounds may face increased risks and require rigorous management.

Although surgical treatment of varicose veins provides significant relief from pain, swelling and cosmetic concerns, it is gradually being replaced by endovenous treatments such as radiofrequency and laser ablation, which offer comparable outcomes with less postoperative pain and faster recovery.

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