Stages of Varicose Veins
Varicose veins are classified using the CEAP system, which includes seven clinical stages (C0-C6) ranging from no visible signs to active venous ulceration. 1
CEAP Clinical Classification System
The CEAP classification provides a standardized framework for characterizing chronic venous disorders based on Clinical, Etiological, Anatomical, and Pathophysiological elements. 2, 3 The clinical component is most widely used in practice and includes the following stages: 1
C0: No Visible Venous Disease
- No visible or palpable signs of venous disease on clinical examination 2
- Patient may still have venous symptoms without visible changes 4
C1: Telangiectasias or Reticular Veins
- Telangiectasias (spider veins) present in 43% of men and 55% of women 1
- Reticular veins are 1-3 mm in diameter 1
- May include redness of the skin around the ankles 2
C2: Varicose Veins
- Varicose veins occur in 16% of men and 29% of women 1
- Dilated, tortuous superficial veins >3 mm in diameter 5
- Patients may be asymptomatic or experience pain, burning, itching, tingling, aching, heaviness, cramping, throbbing, restlessness, and swelling 1, 6
- Symptoms typically worsen at end of day, especially after prolonged standing, and improve with leg elevation 1, 6
C3: Edema
- Presence of edema without skin changes 2
- Swelling in the legs attributable to venous dysfunction 6
- May be difficult to separate venous from other causes of edema 3
C4: Skin Changes
- C4a: Pigmentation or eczema 2
- C4b: Lipodermatosclerosis or atrophie blanche 2
- C4c: Corona phlebectatica (though not formally included in original classification) 7, 3
- Changes in skin pigmentation, eczema, infection, and lipodermatosclerosis indicate progression to more serious underlying vascular insufficiency 1
- Skin changes including tightness and irritation attributable to venous dysfunction 6
C5: Healed Venous Ulcer
- Skin changes described in C4 with signs of healed venous ulcers 2
- History of venous ulceration with current healing 4
C6: Active Venous Ulcer
- Skin lesions with active venous ulcers 2
- Represents most advanced stage of chronic venous insufficiency 8, 4
- Loss of subcutaneous tissue may be present 1
Prevalence by Stage
In a population with mean age of 60 years, the prevalence distribution is: 1
- C0: 29%
- C1: 29%
- C2: 23%
- C3: 10%
- C4: 9%
- C5: 1.5%
- C6: 0.5%
Clinical Implications
Patients are more likely to have symptoms and increasing severity of symptoms with increasing CEAP clinical class. 1 Women are significantly more likely than men to report lower limb symptoms. 1
There is no definitive stepwise progression from spider veins to ulcers—severe skin complications are not guaranteed even with extensive varicose veins. 8 However, the CEAP system helps guide treatment decisions, with symptomatic stages C2s-C6 generally considered indications for invasive therapy. 5
Important Caveats
The CEAP classification is not a severity classification—C2 summarizes all kinds of varicose veins regardless of extent or symptom severity. 3 The clinical classification alone is most commonly used in practice, though the complete CEAP system includes etiological (congenital, primary, or secondary), anatomical (superficial, deep, or perforator veins), and pathophysiological (reflux, obstruction, or both) components. 2, 4, 3