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CEAP classification of the severity of varicose veins

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CEAP clinical score

The C or clinical score from the CEAP classification ranges from C0 which means absolutely no venous disease that can be seen or felt in the legs to C6 which means an open and active venous leg ulcer.

However, whenever using the CEAP clinical score, it is essential to remember that it is only a clinical score. It is quite possible that if a venous duplex ultrasound scan is performed (which should always be the case when assessing any venous disease) then more often than not, worse venous diseases are found deeper inside the leg that cannot be seen by clinical examination alone.

Hence no doctor or nurse who knows anything about varicose veins or vein problems will ever give a full opinion on the clinical grading alone. Without having a venous duplex ultrasound scan performed by a specialist vascular scientist, who can examine all of the veins in the legs and pelvis to look for underlying venous disease, a full diagnosis cannot be given.

The full classification can be seen in the table below.

Please click on the relevant CEAP Clinical classification to be taken to the relevant page.

CEAP Clinical ScoreDescription
C0No visible or palpable varicose veins
C1Telangectasia (Thread veins / Spider veins / Broken veins)
C2C2AVaricose veins without any symptoms (Asymptomatic)
C2SVaricose veins with symptoms
C3Swollen ankle (oedema) due to varicose veins or hidden varicose veins (venous reflux)
C4Skin damage due to varicose veins or hidden varicose veins (venous reflux)
C5Healed venous leg ulcer
C6Venous leg ulcer
CEAP Clinical ScoreDescription
C0No visible or palpable varicose veins
C1Telangectasia (Thread veins / Spider veins / Broken veins)
C2Varicose veins
C2AVaricose veins without any symptoms (Asymptomatic)
C2SVaricose veins with symptoms
C3Swollen ankle (oedema) due to varicose veins or hidden varicose veins (venous reflux)
C4Skin damage due to varicose veins or hidden varicose veins (venous reflux)
C5Healed venous leg ulcer
C6Venous leg ulcer

CEAP classification of varicose veins severity

Although most people with varicose veins will know that they have bulging veins in their legs when they stand up, which tend to disappear when they lie down, it is important to have a grading system to indicate the severity of the varicose vein problem.

Initially, a grading for severity helped doctors communicate with each other. For instance, a family doctor or general practitioner referring a patient with varicose veins to a vein specialist needed to be able to indicate how severe the varicose vein problem was. This would help the specialist know whether the referral was urgent or not.

In addition, those of us who are involved with research into varicose veins and venous diseases need to be able to classify our patients into different groups according to the severity of their varicose vein problem. For instance, one doctor or clinic may claim excellent results with one technique, where as another doctor or clinic may find the same technique does not work so well for their patients. There can be many reasons for this, but one of the easiest to measure is whether both doctors and clinics are actually treating the same sort of patients with the same severity of problem.

Over the last few years, with the National Health Service in the UK and health insurance companies in the UK, USA and elsewhere in the world starting to cut back on funding for varicose vein treatments, it has become important for patients to know how severe their veins are. This is because the decision as to whether a patient can have their veins treated or not often comes down to the severity of their varicose vein problem.

Therefore, it is essential that everybody uses the same classification system to score the severity of varicose veins. By having a uniform system, patients anywhere in the world can be assessed as to their clinical severity and therefore decisions about funding, research or different techniques can be taken.

The most widely used classification for noting the severity of the varicose vein problem in an individual patient is called the CEAP classification.


Cosmetic varicose veins, medical varicose veins and CEAP score

Cosmetic Varicose-Veins or Medical Varicose Veins - CEAP Clinical Score - Mark Whiteley Explains

In the past, and unfortunately even today, a great many doctors, nurses and people in the general public think that varicose veins are “just cosmetic”.

Although some varicose veins are cosmetic, there is a very high proportion of varicose veins and associated venous disease that causes medical problems and therefore is “medical” not “cosmetic”.

Ever since the National Institute of Health and Clinical Excellence (NICE) published its guidelines on varicose veins in July 2013, we have now been able to divide “cosmetic varicose veins” from “medical varicose veins” by using the CEAP clinical score. Please see below for the reference:

Reference: NICE clinical guidelines for varicose veins July 2013 (CG 168)


CEAP classification

The letters CEAP stand for:

C = clinical findings
E = etiological factors (American spelling! UK spelling would be = aetiological factors)
A = anatomical cause
P = pathophysiological cause

When the CEAP classification was first devised, it was thought that every leg with varicose veins could be described and graded by these four factors. However using all four parts of the system makes the classification exceptionally difficult.

Therefore it is now very rare for anyone to use the EAP part of the classification. Whether talking about patients between doctors, publishing research studies or deciding who should get funded by NHS or private medical insurance, almost everybody now just uses the C (clinical) classification from CEAP.