Varicose Veins and Venous Insufficiency in Black Adults

Varicose veins and chronic venous insufficiency (CVI) both come from the same problem: the one-way valves inside your leg veins stop closing properly, so blood pools in the legs instead of flowing back up to the heart. Varicose veins are the visible, ropey, bulging part. CVI is the broader condition, and over years it can damage the skin and cause sores that do not heal. More than 25 million U.S. adults have varicose veins, and more than 6 million have advanced venous disease.

Veins carry blood back to the heart against gravity. In the legs, small valves inside each vein snap shut after blood passes to keep it from sliding back down. When those valves weaken or leak, blood flows backward and pools in the lower leg, a process called venous reflux. The pressure that builds up is venous hypertension, and it is what produces the aching, swelling, and skin damage over time. Varicose veins are the enlarged surface veins you can see. CVI is the downstream effect of that backward flow on the whole leg.

The condition is progressive. Early on it is a cosmetic and comfort issue. Left untreated for years, the constant pressure pushes fluid, blood cells, and iron pigment into the skin, which is where the lasting damage starts.

The veins are the visible clue, but the symptoms are what people actually feel. Common ones include:

• Aching, heaviness, or tiredness in the legs, usually worse at the end of the day or after standing
• Swelling in the ankles and lower legs
• Itching, especially around the ankle
• Night cramps and restless, twitchy legs
• Skin that feels tight or looks discolored near the ankle

Symptoms typically ease when you elevate the legs or walk, and worsen with prolonged standing or sitting. The overlap with restless legs syndrome and ordinary swollen ankles is real, which is part of why CVI gets brushed off. If your ankles and feet swell, the cause is worth pinning down rather than assuming.

Two things work against an early diagnosis in Black patients. First, the bulging veins themselves can be less visually obvious against darker skin, so the surface warning sign that prompts a lighter-skinned patient to get checked may not stand out. Second, when the skin damage does begin, it does not look the way medical textbooks describe it.

The classic teaching is that venous skin changes are red. On brown and Black skin, the same inflammation and iron staining read as brown, gray, purple, or violet rather than red. Stasis dermatitis, the itchy, scaly, discolored skin of long-standing CVI, is routinely missed or misread on darker skin for this reason. The pigment changes get mistaken for a normal part of aging skin, and the underlying vein problem keeps progressing.

This is not a small gap. In a study of 20,648 patients, African American patients with venous stasis presented with more advanced venous disease at younger ages than their white counterparts, with higher rates of ulcer debridement and DVT complications. A separate analysis found skin changes and venous ulcers were most common in African American patients, at 16% and 21%.

The most advanced stage of CVI is a venous leg ulcer, usually an open, shallow, irregular sore near the inner ankle, often with a halo of brown or darkened skin around it. On dark skin, an inflamed, warm, discolored lower leg can be hard to tell apart from cellulitis, a bacterial skin infection. The two are treated completely differently: cellulitis needs antibiotics, while a venous ulcer needs compression and vein care, and antibiotics will not heal it. Getting the wrong label means weeks of the wrong treatment. If you are told you have a skin infection but the leg keeps coming back to the same discolored, swollen state, ask specifically whether your veins have been evaluated.

The well-established risk factors for CVI are family history, pregnancy (and each additional pregnancy adds risk), prolonged standing at work, obesity, a sedentary routine, older age, and a prior deep vein thrombosis. Jobs that keep you on your feet for hours, nursing, teaching, retail, food service, hair and salon work, stack the venous pressure day after day. None of these are unique to Black patients, but several of them, including standing-heavy work and limited access to early specialty care, are unevenly distributed, which helps explain the later, more advanced presentations in the data.

CVI and deep vein thrombosis (DVT) are connected but not the same. DVT is an acute blood clot in a deep leg vein and is a medical emergency, because a piece can break off and travel to the lungs. CVI is the slow, chronic valve problem. The link is that a past DVT can scar and damage the vein valves, and the resulting CVI is then called post-thrombotic syndrome. Post-thrombotic syndrome develops in up to half of people after a DVT, usually within one to two years. If you have ever been treated for a blood clot, ongoing leg swelling and skin changes are not just lingering soreness, they are a recognized complication worth evaluating. For the warning signs of an acute clot, see our guide to DVT and blood clots in Black adults.

The test that confirms CVI is a venous duplex ultrasound. It is non-invasive, painless, and combines a picture of the vein with the speed and direction of blood flow, so it shows exactly which valves are leaking and whether there is reflux or an old clot. There are two standard ultrasound protocols, one for DVT and one for reflux, so it matters that the right one is ordered. A clinician will also examine the legs standing up, since reflux is easier to provoke against gravity. If a primary care visit ends with discoloration written off as dry skin, asking for a venous duplex referral is a reasonable next step.

Treatment is staged. The foundation is conservative care: graduated compression stockings, leg elevation, regular walking to pump the calf muscles, and weight management. Compression is not optional for skin changes or ulcers, it is the core of healing them. When conservative care is not enough, or the reflux is significant, vein-directed procedures close off the failing veins so blood reroutes through healthy ones. Endovenous ablation (using heat or laser through a catheter) and sclerotherapy (injecting a solution that seals the vein) are the common options, both done in an office setting. One caution from the data: a 2020 analysis found African American patients needed more procedures and had worse results after ablation alone, but outcomes evened out when ablation was combined with phlebectomy and sclerotherapy. The takeaway is to ask about a complete treatment plan, not a single procedure.

Start with whoever you see for primary care, and be specific: say your legs ache and swell, that you have noticed skin discoloration or itching at the ankle, and that you want your veins evaluated, not just your skin. Ask for a venous duplex ultrasound and, if reflux is found, a referral to a vascular specialist or vein clinic. If you want a clinician who understands how these skin changes present on darker skin, you can find a Black or Black-serving clinician in our directory. Bring up any history of blood clots, pregnancies, or a standing job, since those shape the diagnosis.