What is superficial phlebitis?

In the extremities there is a deep and superficial venous system. Superficial phlebitis is a local inflammation of a vein that runs superficially (phlebitis). The inflammation of the vein is usually accompanied by clot formation (thrombophlebitis), most often it occurs in a varicose vein (varicophlebitis). A blood clot in the deep veins, phlebothrombosis, must be distinguished from superficial phlebitis.

What are the causes of superficial phlebitis?

The main causes are slowed blood flow, e.g. in varicose veins, during bed confinement, limited mobility or immobilization of the extremities after accidents or operations. Increased blood clotting, such as during pregnancy, postpartum, or after surgery, further increases the risk. Sometimes an increased susceptibility to clotting is also genetically determined. Inflammatory autoimmune diseases, malignant tumor diseases or traumatic injury to the vein wall can also be the reason for superficial phlebitis. One of the most common causes of thrombophlebitis in the arm is an intravenous indwelling catheter (Braunlele), especially if it is left in place too long. The most common cause of superficial phlebitis in the leg is varicose vein disease (varicophlebitis).

What are typical symptoms of superficial phlebitis?

Typical signs of inflammation are redness and overheating of the skin with sometimes significant pain symptoms at this site, especially on pressure, but also on movement. The inflamed vein is palpable as a hard, red and painful cord. In contrast to deep vein thrombosis, swelling of the leg does not occur, since there is no relevant disturbance of blood flow in the deep veins. Rarely, bacterial inflammation of the veins, e.g. via skin lesions, also results in fever with the risk of blood poisoning.

The extent of phlebitis varies greatly; sometimes only a small vein or a short stretch over a few centimeters is affected. Frequently, however, extensive inflammation occurs with extension over a long course of the vein in the upper or lower leg. Especially in larger varicose veins, one often sees pronounced findings in very vigorous dilated veins. Accordingly, the duration of superficial phlebitis varies from a few days to weeks.

What do I do if I suspect superficial phlebitis?

If thrombophlebitis is suspected, a doctor should be consulted immediately and a prompt ultrasound examination of the veins (duplex sonography) should be performed. Treatment of thrombophlebitis depends on the extent of the blood clot in the veins. First, duplex sonography must be used to rule out concomitant thrombosis in the deep veins or even ingrowth of the blood clot into the deep veins. This is because the treatment of venous thrombosis differs from the treatment of superficial phlebitis.

How to treat superficial phlebitis?

Treatment of superficial phlebitis without involvement of deep veins depends on the extent of inflammation. If it ends near the junction with the deep veins, temporary blood thinning should always be performed for 4-6 weeks because of the risk of progression and development of deep vein thrombosis. As a rule, blood thinning is carried out with the subcutaneous administration of heparin injections, which the patient can also give himself without any problems.

The basic therapy for all phlebitis is always a correctly measured compression stocking or compression bandage. The compression stocking should be worn during the day for all activities and can be removed in the evening. Usually, a compression stocking of compression class II is prescribed. Bed rest is not usually necessary – on the contrary, normal everyday mobility prevents progression of thrombophlebitis by stimulating blood outflow.

In addition, anti-inflammatory and analgesic drugs such as ibuprofen or diclofenac are used. Very painful clots in large varicose veins can be relieved at an early stage by a small stab incision. In cases of bacterial inflammation, an antibiotic may also be required. Local cooling and application of anti-inflammatory ointments are generally useful.

In case of varicophlebitis due to varicose vein disease, treatment of varicose veins should be performed during the symptom-free interval. Depending on the type of varicose vein (truncal vein, side branches), minimally invasive catheter procedures, sclerotherapy or surgical stripping are available. Spider veins are very small varicose veins in the skin. They are not a cause of superficial phlebitis, and treatment of spider veins is not medically necessary but often cosmetically desirable.

What is the prognosis for superficial phlebitis?

With correct therapy, this usually heals completely after days to weeks, and the symptoms recede completely. The affected veins often become completely open again and the blood clot dissolves. Often, ultrasound also shows scarred remnants in the veins after the inflammation has healed. Occasionally, the vein remains permanently occluded after inflammation, but this does not result in disruption of blood flow as long as the deep veins are healthy. Occasionally, hyperpigmentation remains in the skin after large superficial thrombosed varicose veins. In the case of varicose veins, permanent closure of the vein after phlebitis would be desirable, as varicose vein intervention may then sometimes be unnecessary.

A special form of superficial phlebitis is thrombophlebitis saltans or migrans. In this case, a frequently recurring phlebitis develops at short intervals in alternating sections of healthy small veins, i.e. not in varicose veins. This always requires further clarification and diagnosis, as it may be related to an infectious disease, autoimmune disease or tumor.

Another special form is sclerosing superficial phlebitis ( Mondor’s disease or iron wire phlebitis) with typical localization on the lateral thoracic wall. As with thrombophlebitis saltans/migrans, there may be a connection to other underlying diseases.

Conclusion

In summary, superficial phlebitis is a relatively common painful condition that occurs mainly on the leg in varicose veins (about 90% of cases). With correct outpatient treatment of superficial vein thrombosis with blood thinners, compression stockings and anti-inflammatory drugs, a rapid freedom from symptoms and healing without complications can be expected. A complication in the sense of deep vein thrombosis is observed in up to 20-30% of cases. In order to exclude this, a prompt ultrasound diagnosis (duplex sonography) should therefore always be performed by a specialist. Short-term duplex sonographic monitoring during therapy is also useful to rule out progression of superficial phlebitis. In the case of varicophlebits (in varicose veins), rehabilitation of the varicose veins should be performed after the inflammation has healed.