Passive Immersion Balneotherapy Safety in Varicose Veins
Passive immersion balneotherapy is probably safe for patients with varicose veins and may provide modest symptomatic benefit, though it should not replace definitive treatment for clinically significant venous insufficiency. 1
Evidence Supporting Safety
Hydrostatic compression during immersion reduces vein size and increases spontaneous venous flow while decreasing reflux in both normal and varicose limbs. 2 This underwater ultrasound study demonstrated that immersion creates beneficial hemodynamic changes through external compression from water pressure, which mechanically supports incompetent veins.
The largest systematic review (7 RCTs, 891 participants) found no serious adverse events reported with balneotherapy for chronic venous insufficiency. 1 The main complications monitored included:
- Erysipelas (OR 2.58,95% CI 0.65 to 10.22) - no clear increase 1
- Thromboembolic events (OR 0.35,95% CI 0.09 to 1.42) - no clear increase 1
- Palpitations (OR 0.33,95% CI 0.01 to 8.52) - no clear increase 1
Modest Clinical Benefits
Balneotherapy probably results in moderate improvement in quality of life (CVIQ2 score reduction: MD -9.38 at 3 months, MD -10.46 at 9 months, MD -4.99 at 12 months) and slight pain reduction (MD -1.23) compared with no treatment. 1 However, there was no clear improvement in disease severity scores (VCSS: MD -1.66,95% CI -4.14 to 0.83). 1
A controlled trial of 61 patients demonstrated significantly greater reduction in leg volume, ankle and calf circumferences with hydrotherapy compared to controls over 3.5 weeks. 3 Subjective symptoms showed more frequent improvement in the hydrotherapy group, though objective venous competence measures were mixed. 3
Critical Limitations and Context
Balneotherapy does not address the underlying pathophysiology of saphenofemoral or saphenopopliteal junction reflux that drives progressive venous disease. 4, 5 The American Family Physician guidelines emphasize that endovenous thermal ablation is first-line treatment for symptomatic varicose veins with documented valvular reflux (reflux ≥500ms, vein diameter ≥4.5mm), achieving 91-100% occlusion rates at 1 year. 4, 5
For patients with CEAP C4-C6 disease (skin changes, lipodermatosclerosis, or ulceration), balneotherapy alone is insufficient and definitive treatment should not be delayed. 4, 6 The American College of Radiology explicitly states that patients with C4 disease require intervention to prevent progression. 4
Clinical Algorithm for Balneotherapy Use
Appropriate candidates for passive immersion balneotherapy:
- CEAP C1-C2 disease (telangiectasias or simple varicose veins without complications) 7, 8
- Mild symptoms (heaviness, aching) without functional impairment 1
- Patients awaiting definitive treatment as adjunctive symptomatic therapy 1
- Those who decline or have contraindications to endovenous procedures 1
Inappropriate as sole therapy:
- Documented saphenofemoral/saphenopopliteal junction reflux ≥500ms requiring ablation 4, 5
- CEAP C4-C6 disease (skin changes, ulceration) 4, 6
- Severe symptoms interfering with activities of daily living 5, 6
- Vein diameter ≥4.5mm with documented reflux 4, 5
Strength of Evidence
The safety evidence is moderate-certainty from a Cochrane systematic review, though limited by lack of blinding and imprecision. 1 The underwater ultrasound study provides proof-of-concept physiologic data but requires larger validation studies. 2 The controlled hydrotherapy trial is low-certainty due to small sample size and single-blind design. 3
The key clinical point: passive immersion is safe but provides only temporary symptomatic relief through mechanical compression, similar to compression stockings but without addressing the underlying venous reflux that drives disease progression. 1, 2 For patients meeting criteria for endovenous ablation (documented junctional reflux ≥500ms, vein diameter ≥4.5mm, failed 3-month compression trial), definitive treatment should not be delayed in favor of balneotherapy alone. 4, 5, 6