Physical Examination

Varicose veins: Note the distribution of varices and any surgical scars.

Corona phlebectatica (ankle/malleolar flare): One of the earliest skin manifestations of CVI comprises dilated intra/subdermal veins at or just below the medial malleolus. Overlying skin is thin and fragile leading to a blue-bleb appearance. Trauma frequently leads to hemorrhage and ulceration.

Lipodermatosclerosis: The skin is brown (red or purple) and indurated due to hemosiderin and plasma protein deposition, leading to dermal fibrosis.

Atrophie blanche: Thin and pale skin due to the thrombotic obliteration of papillary capillaries; often at the site of previous ulceration.

Varicose eczema: Scaly dry (or weeping) skin that is often intensely pruritic and can demonstrate blanching erythema (mimicking cellulitis).

Edema: A common presentation in patients with CEAP class 3 or greater CVI. Chronic venous insufficiency may coexist with other diseases that cause edema, such as


congestive heart failure, and must be considered when evaluating CVI patients (Table 10.3).

Hemorrhage: Can be alarming, even life threatening, may be spontaneous or follow trauma. Direct pressure and elevation always arrest venous hemorrhage. As recurrent bleeding is almost inevitable, the patient should be hospitalized for definitive treatment.

Ulceration: Most CVUs can be easily differentiated from other forms of ulceration.

Arterial circulation: If pedal pulses are impalpable, measure the ankle-brachial index (ABI). An ABI of <0.8 mandates referral to a vascular surgeon. The ABI is unreliable in diabetic patients.

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