The Bottom Line

Varicose veins affect about 20–25% of people and can range from a cosmetic nuisance to a sign of serious venous disease. Symptoms like leg swelling, skin darkening, or a slow-healing wound near your ankle are important warning signs that need medical evaluation — not just cosmetic treatment. A dermatologist can manage many varicose vein cases, but severe disease often warrants referral to a vascular surgeon.

What Are Varicose Veins — and Why Do They Form?

Varicose veins are enlarged, twisted veins visible as bulging blue or purple cords — most commonly on the inner leg, back of the calf, or thigh. They develop when the one-way valves inside your veins stop working properly. These valves normally keep blood moving toward your heart. When they fail, blood flows backward and pools in the vein, creating increasing pressure that stretches and distorts the vessel wall over time.

This is called venous insufficiency. It's a progressive condition — meaning it tends to worsen over time if not addressed. The genes you inherited, your hormones, prior blood clots, long hours of standing, pregnancy, and body weight all influence how quickly it develops.

Varicose Veins vs. Spider Veins: What's the Difference?

Spider veins are small, web-like red or blue lines close to the skin surface. They're usually purely cosmetic and cause no symptoms. Varicose veins are larger, deeper, and more likely to cause symptoms — and they often indicate a more significant problem with venous blood flow. This distinction matters because the two conditions are treated differently, and varicose veins with symptoms require a higher level of medical evaluation.

When Are Varicose Veins Just Cosmetic vs. a Health Concern?

Many people with varicose veins have no symptoms at all and seek treatment because they don't like how their legs look. That's a perfectly valid reason for treatment. But varicose veins are a health concern — and deserve medical evaluation — when they cause:

  • Leg aching, heaviness, or tiredness that worsens throughout the day or after standing
  • Leg or ankle swelling (edema) that gets worse as the day goes on
  • Skin changes near the ankle — darkening of the skin, hardening, or thickening (called lipodermatosclerosis)
  • Itching or burning around the veins
  • A wound or sore near the ankle that is slow to heal or keeps coming back (venous ulcer)
  • Redness, warmth, or tenderness along a vein — which could indicate superficial phlebitis (inflammation)
  • Sudden bleeding from a varicose vein near the skin surface

These symptoms point to advancing chronic venous insufficiency and typically require care beyond what a cosmetic dermatology visit provides.

Warning Signs That Require Urgent Care

Go to an emergency room or urgent care if you experience:

  • Sudden significant swelling in one leg, especially with calf pain — this could be a deep vein thrombosis (blood clot), which is a serious condition
  • A varicose vein that ruptures and bleeds significantly
  • Signs of infection (increasing redness, warmth, fever) around a vein or near a wound

Do You Need a Dermatologist, or a Vascular Surgeon?

The answer depends on what's going on:

  • Dermatologist: A great starting point for cosmetic varicose veins or mild symptoms, especially smaller veins. Dermatologists can perform sclerotherapy and evaluate whether referral is needed.
  • Vascular surgeon or interventional radiologist: Recommended when veins are large, causing significant symptoms, associated with skin changes or ulcers, or have returned after previous treatment. These specialists perform duplex ultrasound imaging and endovenous ablation procedures for more serious cases.
  • Both: Many patients benefit from collaboration — a vascular specialist addressing the underlying insufficiency, then a dermatologist treating residual cosmetic veins.

How Varicose Veins Are Treated

Compression Therapy

Graduated compression stockings (20–30 mmHg) are the first step for symptomatic varicose veins. They don't treat the underlying vein problem, but they reduce aching, swelling, and the feeling of heaviness significantly. Many insurers require a trial of compression before approving ablation procedures.

Sclerotherapy

A dermatologist injects a sclerosing solution — often in foam form for varicose veins — directly into the vein. The solution irritates and damages the vessel wall, causing it to seal shut and be gradually absorbed. Ultrasound guidance is often used to target deeper veins accurately. Success rates are 80–90%, and it's performed in the office without general anesthesia.

Endovenous Ablation (Radiofrequency or Laser)

For larger varicose veins and the underlying saphenous vein insufficiency that drives them, endovenous ablation is the most effective option. A thin catheter is placed inside the vein under ultrasound guidance; heat energy (radiofrequency or laser) is applied along the vein's length, causing it to collapse and seal permanently. Success rates exceed 95%. This is an outpatient procedure done under local anesthesia with minimal recovery time.

Ambulatory Phlebectomy

Small puncture incisions allow a doctor to physically remove bulging vein segments using a hook-like instrument. It's highly effective for surface varicosities and is often combined with ablation for comprehensive treatment.

How to Prevent Varicose Veins from Getting Worse

  • Wear graduated compression stockings if you stand or sit for long periods
  • Take regular walking breaks — the calf muscle acts as a pump that helps push blood back toward the heart
  • Elevate your legs when resting to reduce venous pressure
  • Maintain a healthy weight
  • Avoid prolonged sitting with legs crossed, which increases pressure in the leg veins

What Happens If Varicose Veins Are Left Untreated?

For most people, varicose veins that cause no symptoms don't become dangerous. However, untreated varicose veins with significant insufficiency can progress to more serious complications over years:

  • Worsening edema and skin discoloration
  • Lipodermatosclerosis (painful hardening and thickening of leg skin)
  • Venous ulcers — open wounds near the ankle that are painful and difficult to heal
  • Superficial phlebitis (vein inflammation)
  • Rarely, bleeding from a vein near the skin surface

When to See a Dermatologist

  • You're bothered by the appearance of varicose or spider veins and want to discuss treatment
  • Your legs ache, feel heavy, or swell by the end of the day
  • You notice skin changes near your ankles
  • You want to know whether your veins warrant a referral to a vascular specialist
  • Your varicose veins have returned after previous treatment

Frequently Asked Questions

Are varicose veins dangerous?

Most varicose veins are not medically dangerous and are a cosmetic concern. However, when they cause symptoms — particularly swelling, skin changes, or non-healing wounds — they reflect underlying venous disease that can worsen over time. These cases warrant medical evaluation, not just cosmetic treatment.

Can sclerotherapy fix varicose veins?

Sclerotherapy effectively treats many varicose veins, especially smaller ones. However, larger varicose veins — especially those driven by insufficiency in the saphenous vein — often require endovenous ablation for the best, most durable results. A specialist can determine which approach is right for your specific situation.

When should I see a vascular surgeon instead of a dermatologist?

Consider a vascular surgery referral if you have significant leg swelling, skin changes or ulcers, bulky extensively dilated veins in the saphenous distribution, or if varicose veins have returned after previous sclerotherapy. A vascular specialist can perform duplex ultrasound imaging to assess the full extent of venous insufficiency and recommend the most appropriate procedure.

Can varicose veins come back after treatment?

Treated veins themselves rarely recur. However, the tendency toward venous valve weakness persists, so new varicose veins can develop at different locations over time. The risk depends on your underlying venous anatomy, lifestyle, and how completely the root cause of insufficiency was addressed.

References

  1. Rabe E, et al. Epidemiology of chronic venous disorders in the developed and developing countries. Phlebology. 2020;35(1_suppl):5-12.
  2. Eklof B, et al. Revision of the CEAP classification for chronic venous disorders. J Vasc Surg. 2004;40(6):1248-1252.
  3. Labropoulos N, et al. Chronic venous insufficiency: modern evaluation and management. J Vasc Surg. 2017;65(6):1873-1887.
  4. Gloviczki P, et al. The care of patients with varicose veins and associated chronic venous diseases. J Vasc Surg. 2011;53(5_Suppl):2S-48S.
  5. de Backer TL, et al. Compression therapy for venous leg ulcers. Cochrane Database Syst Rev. 2016;12:CD000265.
  6. Lurie F, et al. The 2020 update of the CEAP classification system and reporting standards. J Vasc Surg Venous Lymphat Disord. 2020;8(3):342-352.

Trusted Resources

Always consult a board-certified dermatologist or vascular specialist for evaluation of varicose veins. This article is for educational purposes only and is not a substitute for personalized medical advice.