Chronic venous insufficiency (CVI) is estimated to affect around 25–30% of the adult UK population to some degree, ranging from mild varicose veins to severe skin changes and venous leg ulcers. It is one of the most common conditions for which patients seek ongoing pharmacy advice — particularly around compression hosiery, leg skin care and symptom management. Community pharmacists who can confidently advise on compression class selection, fitting and adherence support provide a valuable service to this large patient group.

What Is Chronic Venous Insufficiency?

CVI occurs when the valves in the leg veins become incompetent, allowing blood to flow backwards and pool in the lower legs. Over time, the increased venous pressure damages the skin and subcutaneous tissue. The condition is progressive and, without management, can lead to:

• Varicose veins (distended, tortuous superficial veins)
• Ankle and lower leg oedema, worse at the end of the day
• Varicose eczema (venous stasis dermatitis) — itchy, dry, discoloured skin on the lower leg
• Lipodermatosclerosis — hardening and tightening of the skin above the ankle
• Venous leg ulcers — the most serious complication, affecting approximately 1% of the UK adult population at some point

Risk factors include age over 50, female sex, obesity, prolonged standing (occupational), pregnancy, previous deep vein thrombosis and family history.

Compression Hosiery: The Foundation of Management

Graduated compression stockings are the single most effective non-surgical intervention for CVI. They work by applying greatest pressure at the ankle and progressively less pressure up the leg, counteracting the venous pooling caused by valve incompetence.

Compression classes available in UK pharmacies

Class 1 and Class 2 stockings are widely available over the counter. Class 3 is usually supplied on prescription and may require specialist fitting.

Fitting advice

Correct fit is essential for efficacy and comfort. Pharmacists should advise patients to:

• Measure leg circumference at the ankle, calf and thigh (depending on stocking length) first thing in the morning, before oedema develops
• Choose below-knee stockings for most CVI presentations — they are better tolerated and equally effective for below-knee symptoms
• Apply stockings first thing in the morning before standing
• Use rubber gloves or a stocking applicator aid for patients with reduced hand strength (common in the elderly population who need them most)
• Replace stockings every 3–6 months, as the elastic deteriorates and compression diminishes

Adherence barriers

Compression therapy is only effective if patients wear the stockings consistently. Common barriers include:

• Difficulty putting on and removing stockings (especially for elderly patients with limited dexterity)
• Discomfort in warm weather
• Cosmetic concerns
• Skin irritation

Pharmacists can address these by recommending stocking applicator devices (e.g. Medi Butler, Jobst applicator), open-toe styles for summer wear, and emollient application before donning stockings to reduce friction.

Skin Care for Varicose Eczema

Venous eczema (stasis dermatitis) is extremely common in CVI and presents as dry, itchy, reddish-brown skin on the lower leg, often with scaling. Pharmacists can recommend:

• Emollients — generous, frequent application of a fragrance-free emollient (Diprobase, Cetraben, Doublebase) to maintain the skin barrier. This is the most important self-care measure
• Hydrocortisone 1% cream — for acute flares of itching and inflammation, applied thinly for up to 7 days
• Avoid soap — use an emollient wash instead to prevent further drying
• Avoid topical antibiotics (e.g. neomycin, fusidic acid) unless specifically prescribed — contact sensitisation rates are high in venous eczema patients

The characteristic brown discolouration (haemosiderin staining) of CVI is permanent and does not indicate active infection. Pharmacists should reassure patients that this staining is a cosmetic consequence of previous venous congestion, not a sign of worsening disease.

Leg Elevation and Lifestyle Advice

Alongside compression, pharmacists can counsel patients on:

• Elevating legs above heart level for 30 minutes three to four times daily — this actively reduces venous pressure and oedema
• Regular walking — calf muscle contraction pumps venous blood upward and is the body's natural compression mechanism
• Avoiding prolonged standing or sitting — if occupational standing is unavoidable, suggest regular breaks to walk or elevate
• Maintaining a healthy weight — excess weight increases intra-abdominal pressure and worsens venous reflux
• Ankle exercises — dorsiflexion and plantarflexion while seated can improve calf pump function

When to Refer

Pharmacists should refer patients to their GP if:

• There is a suspected venous ulcer (any break in the skin on the lower leg that has not healed within 2 weeks)
• The leg is suddenly swollen, red and hot — possible DVT requiring urgent assessment
• Varicose eczema is not responding to emollients and OTC hydrocortisone after 7 days
• The patient has suspected arterial disease (absent pedal pulses, claudication) — compression is contraindicated in significant peripheral arterial disease
• There is cellulitis (spreading redness, fever, warmth) — requires antibiotics

Critical safety point: Compression stockings must not be applied to limbs with significant peripheral arterial disease or undiagnosed leg ulcers. If there is any doubt about arterial supply, refer for ankle-brachial pressure index (ABPI) measurement before recommending compression.

Products Available in Pharmacy

• Graduated compression stockings (Class 1 and 2 — brands include Scholl, Activa, Duomed)
• Stocking applicator aids
• Emollients (Diprobase, Cetraben, Doublebase, Epaderm)
• Hydrocortisone 1% cream
• Emollient wash products (Dermol 500, Cetraben wash)
• Leg elevation cushions

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Sources: NICE CG168 Varicose Veins, NICE CKS Venous Leg Ulcers, British National Formulary, British Lymphology Society compression guidelines.