Marion came to the case management office to talk about her discharge plan after a knee replacement. She was sixty-four, a retired postal worker who had been on her feet for three decades. When she lowered herself into the chair across from me, I noticed the veins along her calves before I noticed much else. They were ropy and dark, the kind that have been there a long time, and the skin at her right ankle had taken on a brownish cast I recognized immediately.
“How long have you had those?” I asked.
She glanced down. “The veins? Forever. My mother had them. I’ve been wearing those compression stockings from the drugstore for years. They don’t bother me much.” She paused. “Should I be worried?”
That question is exactly the right one. And the honest answer isn’t simple.
Varicose veins develop when the small one-way valves inside the veins stop working properly. Veins carry blood back to the heart, and in the legs, they’re fighting gravity to do it. Those valves open to let blood move upward and close to prevent it from sliding back. When a valve weakens or fails, blood pools. The vein swells, stretches, and eventually becomes visible through the skin, sometimes protruding above it.
There are two common presentations, and they have very different implications. Spider veins are tiny, close to the skin’s surface, and form a web of fine red or purple lines. They’re mostly cosmetic. Varicose veins are larger, often bulging, and develop in the deeper layer of the superficial venous system. Whether they’re purely cosmetic or a genuine medical concern depends not on how they look, but on what they’re doing.
The distinction that matters is whether the veins are producing symptoms. Many people have varicose veins that look alarming and feel like nothing. Many others have veins that don’t look that bad but produce significant aching, heaviness, or swelling, particularly after a long day on their feet. That aching is a signal worth paying attention to. It means the venous system is struggling to move blood efficiently, a condition doctors call chronic venous insufficiency.
Symptoms that indicate something more than a cosmetic issue include persistent swelling in the ankles or lower legs that doesn’t resolve after a night of sleep, a feeling of heaviness or fatigue in the legs, itching or burning over the veins, and restlessness that worsens in the evenings. On the more serious end of the spectrum: skin changes near the ankle, particularly a brownish discoloration or skin thickening, indicate that blood is leaking into surrounding tissue. Open sores near the ankle, called venous ulcers, are the most severe manifestation of untreated venous insufficiency. They’re slow to heal and prone to infection.
Marion’s ankle discoloration was exactly that. Not an emergency, but a sign that her vein problem had moved from cosmetic to clinical.
Some symptoms shouldn’t wait for a routine appointment. Sudden, severe pain or warmth in a varicose vein can indicate superficial thrombophlebitis, an inflammation of the vein that requires prompt evaluation. Any bleeding from a varicose vein needs attention the same day. And symptoms that might suggest a deep vein thrombosis (significant one-sided leg swelling, pain that came on quickly, redness or warmth spreading up the leg) are a reason to go to urgent care or an emergency room.
For everyone else, the right first step is a conversation with a primary care physician, or a referral to a vascular specialist or phlebologist if symptoms are pronounced. Many people put this off for years because they assume varicose veins are just a cosmetic nuisance, or because they assume treatment means surgery. Neither assumption holds up.
Compression stockings are the established first-line treatment for symptomatic varicose veins. Not the thin nylon hosiery at the drugstore, but medical-grade graduated compression, typically in the 20-30 mmHg range for mild to moderate venous insufficiency. Research supports their use for symptom relief: reduced aching, less swelling, slowed progression. What they don’t do is make existing varicose veins disappear, and they don’t repair underlying valve failure. What they do is help the veins do their job better despite that failure. For many people, that’s enough.
For those who want to treat the veins themselves, the approach depends on the size and location of what’s involved.
Sclerotherapy is the standard approach for spider veins and smaller varicose veins. A physician injects a solution directly into the vein, irritating the vessel wall and causing it to collapse and be absorbed over time. Multiple sessions are often needed. Temporary bruising and skin discoloration at injection sites are common, and both typically resolve. The Mayo Clinic and the Cleveland Clinic both recognize sclerotherapy as effective and appropriate for smaller vessels.
For larger varicose veins, particularly those involving the great saphenous vein running along the inner leg, the current standard of care is endovenous thermal ablation. This is done with either laser energy (endovenous laser ablation, or EVLA) or radiofrequency energy (radiofrequency ablation, or RFA). The procedure involves threading a thin catheter into the vein under ultrasound guidance and applying heat to seal it shut. It’s done under local anesthesia in an outpatient setting. Most people are walking the same day and return to normal activity within a week. Published trials show success rates above 90%. This approach has largely replaced surgical stripping as the standard choice.
Ambulatory phlebectomy is sometimes done alongside ablation or independently for surface varicosities. The physician makes small incisions to remove the affected vein directly. It’s also outpatient and performed under local anesthesia.
Surgical stripping, which was once the default procedure, is now rarely necessary. It involves removing the affected vein through incisions, typically under general or spinal anesthesia, with a longer recovery. Multiple systematic reviews in vascular surgery literature have found that endovenous thermal techniques produce equivalent or better long-term outcomes with fewer complications. Surgical stripping is still used in specific anatomical situations or when ablation has not succeeded, but it’s no longer where treatment begins.
What doesn’t work is worth being direct about. The vein health market has attracted a lot of products built on vague claims and wishful marketing.
Elevation helps temporarily. Putting your feet up at the end of the day reduces swelling and relieves discomfort. It doesn’t repair valves and doesn’t address the structural problem. It’s supportive, not corrective.
Topical creams marketed for varicose veins have no reliable clinical evidence behind them. The appearance of veins that develop under the skin can’t be altered by anything applied to the surface.
Supplements are a more complicated story. Horse chestnut seed extract has the most evidence of anything in this category: a Cochrane systematic review found some support for symptom relief (edema, heaviness, pain) in people with chronic venous insufficiency, and the effect is considered modest at best. No supplement repairs a failed valve. Diosmin, grape seed extract, and similar preparations have limited and inconsistent evidence. The marketing for these products tends to be confident. The research isn’t. Those two things don’t align, and it’s worth noticing the gap.
Marion was referred to a vascular surgeon, who confirmed chronic venous insufficiency and recommended a course of medical-grade compression stockings, with ablation as an option if her symptoms worsened or if the skin changes progressed. She was relieved to have a name for what she’d been tolerating for years, and a plan that didn’t involve anything drastic.
That’s usually how this goes. Varicose veins are common, often manageable, and occasionally a sign of something that warrants real attention. The mistake is in writing them off as cosmetic before asking whether they’re producing symptoms. The other mistake is assuming that treatment means surgery, when in most cases the path starts somewhere much more manageable.
Questions worth bringing to your doctor
Before your appointment, it helps to come in with some specific questions rather than a general complaint about your legs. Ask your doctor whether your veins are producing symptoms that indicate venous insufficiency, or whether what you have is primarily cosmetic. Ask whether a duplex ultrasound is appropriate to evaluate the blood flow in your veins, since that’s the diagnostic test that distinguishes the severity of the problem. If you’re already wearing compression stockings, ask whether the grade and fit are correct for your situation, since medical-grade compression is different from what’s sold at most pharmacies. If you’re a candidate for a procedure, ask what the difference is between sclerotherapy and endovenous ablation in your specific case, what to expect in terms of recovery and results, and how many sessions you might need. And ask what symptoms should prompt you to call sooner rather than waiting for a routine follow-up.
For further reading, the Mayo Clinic’s page on varicose veins and the Cleveland Clinic’s overview of treatment options both offer reliable, evidence-based summaries that are worth reviewing before your appointment.
Carol Gifford spent fourteen years as a registered nurse before moving into health communication and writing. She covers medicine and wellness for the Sunday Evening Review. She does not offer medical advice. Talk to your doctor about your specific situation.
