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ACTUALIZAREA GHIDULUI NAÞIONAL DE BOALÃVENOASÃ CRONICÃ

UPDATING CHRONIC VENOUS DISEASE NATIONALGUIDELINE

CÃLIN GIURCÃNEANU*, ALEXANDRU TÃTARU**, MARIA ROTARU***, LAURA GHEUCÃ SOLOVÃSTRU****, CÃTÃLIN POPESCU*****,

MARIA MAGDALENA CONSTANTIN*****, IRINEL NEDELCU*****, ALIN NICOLESCU******

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REFERATE GENERALEGENERAL REPORTS

Rezumat

Boala venoasã cronicã este o afecþiune produsã dealterarea funcþiei valvulelor venoase, atât în sistemul venossuperficial, de joasã presiune, cât ºi în sistemul venosprofund, de presiune înaltã al membrelor inferioare.

Netratatã, boala venoasã cronicã are o evoluþieprogresivã, puþin reversibilã, realizând alterãri importanteale calitãþii vieþii pacientului, ajungându-se, în ultimelestadii, la invaliditate. Hemoragia, tromboflebita, infecþia ºitrombembolismul pulmonar complicã frecvent ultimelestadii ale bolii venoase cronice.

În prezent, boala venoasã cronicã a membrelorinferioare este o importantã problemã de sãnãtate publicã.Se apreciazã cã între 2%-5% din populaþia statelorindustrializate prezintã diverse grade de boalã venoasã amembrelor inferioare, refluxul venos fiind mecanismulfiziopatologic întâlnit în 30%-40% din aceste cazuri.

Simptomatologia extrem de diversã a bolii venoasecronice apare progresiv pe o lungã perioadã de timp ºinecesitã o adaptare permanentã a terapeuticii, care trebuiesã rãspundã caracteristicilor clinice ºi fiziopatologice alefiecãrei etape de evoluþie a bolii.

Summary

Chronic venous disease is a condition that occurs whenthe function of venous valves, both in the low-pressure,superficial venous system and the high-pressure, deepvenous system in lower extremities, is altered.

Left untreated, chronic venous disease has aprogressive, little reversible evolution, causing significantalterations of the patient’s quality of life and developingdisability when the condition reaches advanced stages.Haemorrhage, thrombophlebitis, infection and pulmonaryembolism are common complications in the advanced stagesof chronic venous disease.

Currently, chronic venous disease in lower extremitiesis a major public healthcare problem. Estimates show thatabout 2%-5% of the population in developed countries havedifferent stages of chronic venous disease of lowerextremities, venous reflux being the physiopathologicalmechanism incriminated in 30%-40% of these cases.

Highly diverse symptoms of chronic venous disease areexperienced progressively, during a long period of time, andrequire an ongoing adjustment of therapy that shouldanswer to clinical and physiopathological characteristics ofeach stage of chronic venous disease.

We submit a therapy guideline for chronic venousdisease of lower extremities, based on the personal clinical

* Spitalul Universitar de Urgenþã „Elias“, Bucureºti.** Clinica Dermatologie, Cluj-Napoca.*** Clinica Dermatologie, Sibiu.**** Clinica Dermatologie, Spitalul „Sf. Spiridon“ Iaºi.***** Spitalul Clinic Colentina, Bucureºti.****** CMDT Roma, Bucureºti.

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DermatoVenerol. (Buc.), 60: 187-195

În urma modificãrilor aduse terminologieibolii venoase cronice ºi a noii clasificãri CEAP,precum ºi apariþiei unor tehnici chirurgicalerevoluþionare (ablaþie endovenoasã, laser terapie,etc), dar ºi ca urmare a actualizãrii ghidurilorinternaþionale de practicã pe seama studiilorrecent publicate incluzând soluþii farmacologiceinovatoare pentru respectiva patologie (formulãrifarmaceutice moderne precum fracþiuneaflavonoidicã purificatã micronizatã, dar ºiproduse biologice originale menite sã ameliorezehemodinamica ºi sã refacã structurile vascularedeteriorate ca urmare a acþiunilor lor vasculo-trope ºi antitrombotice, precum sulodexiduloriginal), Societatea Românã de Dermatologie,prin colegiul sãu ºtiinþific, a hotãrât revizuirea ºiactualizarea ghidului românesc de boalã venoasãcronicã datând din anul 2010 (OMS 1218, anexa 17).

Reprezentanþi de marcã ai Colegiului ºtiin-þific al Societãþii Române de Dermatologie (Prof.Dr. Cãlin Giurcãneanu, Prof. Dr. AlexandruTãtaru, Prof. Dr. Maria Rotaru, Prof. Dr. LauraGheucã Solovãstru, Conf. Dr. Cãtãlin Popescu,Dr. Alin Nicolescu ºi Dr. Irinel Nedelcu) adunaþisã analizeze temeinic referinþele bibliograficerelevante publicate între 2009 ºi 2015, în specialghidurile actualizate europene ºi americane aleunor prestigioase societãþi medicale de profil, aureuºit în final sã elaboreze forma revizuitã ºiactualizatã a ghidului naþional de boalã venoasãcronicã pe care o dãm publicitãþii în prezentulnumãr al Revistei Societãþii Române de Dermato-logie.

Odatã cu revizuirea ºi actualizarea ghiduluiromânesc de boalã venoasã cronicã, SocietateaRomânã de Dermatologie se va alinia principiilorde diagnostic ºi tratament ale acestei boli caresunt folosite în prezent atât la nivel european, câtºi pe teritoriul Statelor Unite ale Americii. Astfel,

Following the amendments performed on theterminology of chronic venous disease and thenew CEAP classification, as well as following thedevelopment of ground-breaking surgicaltechniques (endovenous ablation, laser therapy,etc.), as well as following the update ofinternational practice guidelines based onrecently published studies, including innovativepharmacological solutions for the specificpathology (modern pharmaceutical formulassuch as micronized purified flavonoid fraction, aswell as original biological products intended toimprove hemodynamics and to restore vascularstructures due to their vasculotropic andantithrombotic actions, such as originalsulodexide), the Romanian Society ofDermatology, through its scientific college, hasdecided to review and update the RomanianGuideline of Chronic Venous Disease as of 2010(MoH Order 1218, anex 17).

Renowned representatives of the ScientificCollege of the Romanian Society ofDermatology (Prof. Dr. Cãlin Giurcãneanu, Prof.Dr. Alexandru Tãtaru, Prof. Dr. Maria Rotaru,Prof. Dr. Laura Gheucã Solovãstru, Assoc. Prof.Dr. Cãtãlin Popescu, Dr. Alin Nicolescu and Dr.Irinel Nedelcu) gathered to thoroughly analysethe relevant bibliographic references publishedbetween 2009 and 2015, mainly the updatedEuropean and US guidelines issued byprestigious medical societies, have finallysucceeded in drawing the reviewed andupdated form of the national guideline forchronic venous disease which we release in thisissue of the Journal of the Romanian Society ofDermatology.

Pursuant to the review and update of theRomanian Guideline for Chronic Venous Disease,the Romanian Society of Dermatology shall alignto the principles for diagnosis and treatment ofthis disease currently used both at European level

Prezentãm un ghid terapeutic al bolii venoase cronicea membrelor inferioare, rezultat din experienþa clinicãpersonalã a autorilor, în concordanþã cu experienþa clinicãinternaþionalã ºi cu ghidurile terapeutice existente înprezent la nivel mondial.

Cuvinte cheie: boala venoasã cronicã, tratament, ghid.

experience of the authors, in compliance with theinternational clinical experience and with current therapyguidelines available worldwide.

Key words: chronic venous disease, treatment,guidelines.

Intrat în redacþie: 26.08.2015Acceptat: 22.09.2015

Received: 26.08.2015Accepted: 22.09.2015

se vor deschide medicilor dermatologi români (ºinu numai!) noi orizonturi de colaborare cu altesocietãþi de profil europene ºi americane folosindo terminologie comunã pentru diagnosticul ºitratamentul acestei patologii, ceea ce în final enumai spre binele pacienþilor.

BOALA VENOASÃ CRONICÃA MEMBRELOR INFERIOARE

GHID NAÞIONAL DE TRATAMENT

Definiþie

Boala Venoasã Cronicã (BVC) este caracte-rizatã de simptome ºi semne instalate ca rezultatal alterãrilor structurale ºi funcþionale ale venelor.Termenul de ,,Boalã Venoasã Cronicã” includetoate stadiile de boalã conform clasificãrii CEAP(clinicã, etiologicã, anatomicã ºi patologicã), dia-gnosticul precis fiind pus pe seama simptomelorºi a semnelor clinice împreunã cu examenuldoppler venos.

Simptomele caracteristice sunt senzaþia depicior greu, senzaþia de picior obosit, crampelepredominant nocturne, durerea, pruritul, sen-zaþia de arsurã sau senzaþia de picior umflat.

Semnele includ telangiectazii, vene reticulare,vene varicoase, edemul, modificãrile trofice cuta-nate cum ar fi lipodermatoscleroza, dermatita,pigmentarea ºi, în stadiile evolutive finale, ulce-raþia. Termenul de Insuficienþã Venoasã Cronicã(IVC) este rezervat stadiilor severe de BoalãVenoasã Cronicã (C3-C6) însoþite de leziunimorfologice ºi funcþionale severe cu alterareasemnificativã a calitãþii vieþii.

Epidemiologie

La nivel mondial 10-33% din femeile adulte ºi10-20% din bãrbaþi au Boalã Venoasã Cronicã. Înstatele europene prevalenþa este chiar mai marede 20 pânã la 50%, ultimele date ajungând chiarla procente de pânã la 85%.

În România studii epidemiologice recente curelevanþã naþionalã au arãtat o prevalenþã a BVCde 32%.

Tratament

Tratamentul bolii venoase cronice este com-plex, se face în funcþie de stadiul bolii ºi include:

and in the US. Thus, new horizons shall open forRomanian dermatologists (and not only!)regarding the collaboration with other Europeanand US societies in the field, using a commonterminology for the diagnosis and treatment ofthis disorder, which in the end only benefits topatients.

CHRONIC VENOUS DISEASE OF LOWER EXTREMITIES NATIONAL

GUIDELINE OF TREATMENT

Definition and epidemiology

Chronic Venous Disease is characterised bysymptoms and signs occurring as a result ofstructural and functional alterations of veins. Theterm “Chronic Venous Disease (CVD)” includesall disease stages according to CEAPclassification (clinical, etiological, anatomical andpatho-physiological), as the accurate diagnosis isestablished based on clinical symptoms andsigns, along with the Doppler venous exam.

Specific symptoms include heavy legsensation, tired leg sensation, predominantlynocturnal cramps, pain, pruritus, burn sensationor swollen foot sensation.

Signs include telangiectasias, reticular veins,varicose veins, oedema, trophic cutaneouschanges such as lipodermatosclerosis, dermatitis,pigmentation and, in final development stages,ulcers. The term of chronic venous insufficiency(CVI) is reserved to severe stages of chronicvenous disease (C3-C6) accompanied by severemorphological and functional lesions, withsignificant alteration of the quality of life.

Epidemiology

Globally, 10-33% of adult women and 10-20%of men have chronic venous disease. In Europeancountries, prevalence is even higher than 20-50%,the last data reaching even 85%.

In Romania, recent epidemiological studieswith national relevance have shown a CVDprevalence of 32%.

Treatment

The treatment of chronic venous disease iscomplex, is performed according with the stageof the disease and includes: hygiene and diet,

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regimul igieno-dietetic, terapia medicamentoasã(sistemicã sau localã), terapia compresivã, terapialocalã a ulcerului venos, scleroterapia, terapiaendovenoasã (vapori, laser endovenos, radio-frecvenþã, etc), tratamentul chirurgical ºi terapiacu laser vascular.

Tratamentul bolii venoase cronice se stabi-leºte funcþie de stadiul bolii, dupã protocolul demai jos, tratamentul sistemic putând fi iniþiatinclusiv de cãtre medicul de familie.

0. Pacienþi cu Boalã Venoasã Cronicã înstadiul CEAP COs

Descrierea stadiului conform clasificãriiCEAP revizuite:– pacienþi fãrã semne palpabile sau vizibile

de Boalã Venoasã Cronicã, dar cu simptomecaracteristice: durere, senzaþie de piciorgreu, senzaþie de picior umflat, crampemusculare, prurit, iritaþii cutanate ºi oricarealte simptome atribuibile Bolii VenoaseCronice.

Modalitãþi terapeutice:– schimbarea stilului de viaþã;– identificarea ºi înlãturarea/tratarea facto-

rilor favorizanþi ºi/sau a comorbiditãþilor;– tratament sistemic:

� diosminã (450 mg) ± hesperidinã (50mg), 2 tablete zilnic;

� sulodexid 2 capsule a 250 ULS pe zi (1capsulã a 250 ULS de 2 ori pe zi), întremesele principale, tratament cronic;

� oligomeri procianidolici;� alte flebotonice;

– contenþie elasticã în funcþie de fiecare cazîn parte.

1. Pacienþi cu Boalã Venoasã Cronicã înstadiul CEAP C1

Descrierea stadiului conform clasificãriiCEAP revizuite:– pacienþi cu telangiectazii (venule intra-

dermice confluate ºi dilatate cu diametrulmai mic de 1 mm) sau vene reticulare (venesubdermice dilatate, cu diametrul între 1 ºi3 mm, tortuoase).

drug therapy (systemic or local), compressivetherapy, local therapy of venous ulcer,sclerotherapy, endovenous therapy (vapours,endovenous laser, radiofrequency, etc.), surgicaltreatment and vascular laser therapy.

The treatment of chronic venous disease isdetermined according to the stage of the disease,after the protocol below, as treatment can beinitiated including by the family doctor.

0. Patients with Chronic Venous Diseasein CEAP COs stage

Description of the stage according to thereviewed CEAP classification:- patients without visible and palpable signs

of Chronic Venous Disease, but withcharacteristic symptoms: pain, heavy footsensation, swollen foot sensation, musclecramps, pruritus, skin rashes and anyother symptoms attributable to theChronic Venous Disease.

Therapy methods:- lifestyle changes;- identification and removal/treatment of

aggravating factors and/or comorbidities;- systemic treatment:

� diosmin (450 mg) ± hesperidin (50 mg),2 tablets daily;

� sulodexide 2 capsules x 250 LSU daily (1capsule x 250 LSU, 2 times per day),between the main meals, chronictreatment;

� procyanidolic oligomers;� other phlebotonics;

- elastic contention depending on each case.

1. Patients with Chronic Venous Diseasein CEAP C1 stage

Description of the stage according to thereviewed CEAP classification:– patients with telangiectasias (conflated

and dilated intradermal venules with adiameter below 1 mm) or reticular veins(dilated subdermal veins, with a diameterbetween 1 and 3 mm, tortuous).

Therapy methods:

– lifestyle changes;

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Modalitãþi terapeutice:

– schimbarea stilului de viaþã;– identificarea ºi înlãturarea/tratarea facto-



� sulodexid 2 capsule a 250 ULS pe zi (1capsulã a 250 ULS de 2 ori pe zi), întremesele principale, tratament cronic;


– contenþie elasticã în funcþie de fiecare cazîn parte;

– scleroterapie;– laser vascular (PDL, Nd:YAG, diodã, etc.).


Descrierea pacienþilor conform clasificãriiCEAP revizuite:– pacienþi cu vene varicoase – dilataþii

venoase subcutanate mai mari de 3 mmdiametru în ortostatism. Acestea pot sãimplice vena safenã, venele tributaresafenei sau venele nonsafeniene. Au celmai frecvent un aspect tortuos.


– schimbarea stilului de viaþã;– identificarea ºi înlãturarea/tratarea fact-

orilor favorizanþi ºi/sau a comorbidi-tãþilor;

– tratament sistemic:� sulodexid 2 capsule a 250 ULS pe zi (1

capsulã a 250 ULS de 2 ori pe zi), întremesele principale, tratament cronic;



– contenþie elasticã în funcþie de fiecare cazîn parte;

– scleroterapie;– laser vascular (PDL, Nd:YAG, diodã, etc.);– terapie endovenoasã;– tratament chirurgical *.

* Tehnica va fi selectatã în funcþie de fiecare caz în parteºi în funcþie de dotarea ºi experienþa centrului medical.

– identification and removal/treatment ofaggravating factors and/or comorbidities;

– systemic treatment:� diosmin (450 mg) ± hesperidin (50 mg),

2 tablets daily;� sulodexide 2 capsules x 250 LSU daily (1

capsule x 250 LSU, 2 times per day),between the main meals, chronictreatment;


– elastic contention depending on each case;– sclerotherapy;– vascular laser (PDL, ND:YAG, diode, etc).


Description of patients according to thereviewed CEAP classification:– patients with varicose veins -

subcutaneous venous dilations, with adiameter above 3 mm while standing.These could involve the saphenous vein,the tributaries of the saphenous vein or thenon-saphenous vein. Most frequently theyhave a tortuous appearance.

Therapy methods:

– lifestyle changes;– identification and removal/treatment of

aggravating factors and/or comorbidities;– systemic treatment:

� sulodexide 2 capsules x 250 LSU daily (1capsule x 250 LSU, 2 times per day),between the main meals, chronictreatment;



– elastic contention depending on each case;– sclerotherapy;– vascular laser (PDL, Nd:YAG, diode, etc.);– endovenous therapy;– surgical treatment*.

* The technique shall be selected depending on each caseand on the endowment and experience of the medical centre.

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Descrierea pacientului în conformitate cuclasificarea CEAP revizuitã:– pacienþi cu edeme – definite ca ºi creºterea

perceptibilã a volumului de fluide la nive-lul pielii ºi þesutului celular subcutanat,evidenþiabil clinic prin semnul godeului.De cele mai multe ori edemul apare înregiunea gleznei, dar se poate extinde lapicior ºi, ulterior, la nivelul întreguluimembru inferior.




� sulodexid 4 capsule a 250 ULS pe zi (2capsule a 250 ULS de 2 ori pe zi, întremesele principale), pânã la dispariþiaclinicã a edemului, apoi 2 capsule a 250ULS pe zi (1 capsulã a 250 ULS de 2 oripe zi), între mesele principale, tratamentcronic;



– contenþie elasticã - în funcþie de fiecare cazîn parte.



Descrierea pacientului conform clasificãriiCEAP revizuite:C4a – pacienþi care prezintã:– pigmentaþia - colorarea brun închis a pielii

datoritã extravazãrii hematiilor. Apare celmai frecvent în regiunea gleznei, dar sepoate extinde cãtre picior, gambã ºi ulteriorcoapsã.



Description of patient according to thereviewed CEAP classification:– patients with oedema - defined as

perceivable increase of the volume offluids at the skin and subcutaneous celltissue level, clinically distinguishablethrough the well sign. Most of the time, theoedema occurs in the ankle region, but canalso extend to the leg and, further, to theentire lower extremity.

Therapy methods:



� sulodexide 4 capsules x 250 LSU daily (2 capsules x 250 LSU, 2 times per day),

between the main meals, until theclinical cure of oedema, followed by 2capsules x 250 LSU daily (1 capsule x250 LSU, 2 times per day) between themain meals, chronic treatment;



– elastic contention depending on each case;– sclerotherapy;– vascular laser, diode, etc.;– endovenous therapy;– surgical treatment*.


Description of the patient according to thereviewed CEAP classification:C4a - patients with:– pigmentation - dark brown colouring of

the skin as a result of erythrocyteextravasation. Most frequently occurs inthe ankle area, but can also extend to thefoot, leg and further to the thigh.


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– Eczema: dermatita eritematoasã care sepoate extinde la nivelul întregului membruinferior. De cele mai multe ori este loca-lizatã în apropierea varicelor, dar poateapãrea oriunde la nivelul membruluiinferior. Este cel mai frecvent consecinþaInsuficienþei Venoase Cronice, dar poate sãfie ºi secundarã tratamentelor localeaplicate.

C4b – pacienþi care prezintã:– Lipodermatosclerozã: fibrozã postinflama-

torie cronicã localizatã a pielii ºi þesutuluicelular subcutanat, asociatã în unele cazuricu contracturã a tendonului Ahilean.Uneori este precedatã de edem inflamatordifuz, dureros. În acest stadiu preteazã ladiagnostic diferenþial cu limfangita, erizi-pelul sau celulita. Este un semn al Insufi-cienþei Venoase Cronice foarte avansate.

– Atrofie albã: zone circumscrise de tegu-ment atrofic, uneori cu evoluþie circum-ferenþialã, înconjurate de capilare dilatateºi uneori de hiperpigmentare.




� sulodexid 4 capsule a 250 ULS pe zi (2capsule a 250 ULS de 2 ori pe zi, întremesele principale), pânã la dispariþiatulburãrilor de troficitate cutanatã,apoi 2 capsule a 250 ULS pe zi (1 capsulãa 250 ULS de 2 ori pe zi), între meseleprincipale, tratament cronic;






– Eczema: erythematous dermatitis that canextend on the entire surface of the lowerextremity. Most of the time, it is locatednear varicose veins, but it can occuranywhere on the lower extremity. It is mostfrequently the consequence of ChronicVenous Insufficiency, but can also berelated to local treatments applied.

C4b - patients with:– Lipodermatosclerosis: localised chronic

post-inflammatory fibrosis of skin andsubcutaneous cell tissue, sometimesassociated with Achilles tendoncontracture. Sometimes it is preceded bydiffuse, painful inflammatory oedema. Inthis stage, a differential diagnosis oflymphangitis, erysipelas or cellulitis isconsidered. This is a sign of very advancedChronic Venous Insufficiency.

– White atrophy: circumscribed atrophytegument areas, sometimes withcircumferential progress, encircled bydilated capillaries and sometimes byhyperpigmentation.

Therapy methods:



� sulodexide 4 capsules x 250 LSU daily (2capsules x 250 LSU, 2 times per day)between the main meals), until all skintrophicity disorders are cured, then 2capsules x 250 LSU daily (1 capsule x250 LSU, 2 times per day), between themain meals, chronic treatment;



– elastic contention depending on each case;– sclerotherapy;– vascular laser, diode, etc.;– endovenous therapy;– surgical treatment*.


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Bibliografie/Bibliography

1. Management of chronic venous disorders of the lower limbs Guidelines According to Scientific Evidence(The European Venous Forum, The International Union of Angiology, The Cardiovascular Disease Educational and ResearchTrust (UK), Union Internationale de Phlebologie. International Angiology, Ch. 18, April 2014)

2. Management of Chronic Venous Disorders of the Lower Limbs: Guidelines according to Scientific Evidence(International Angiology, vol 27, febr. 2008)

5. Pacienþi cu Boalã Venoasã Cronicã înstadiul CEAP C5, C6

Definirea tipului de pacient conform cuclasificarea CEAP revizuitã:C5 - ulcer venos vindecatC6 - ulcer venos activ - leziune ce afecteazã

tegumentul în totalitate, cu pierdere de substanþãcare nu se vindecã spontan. Apare cel maifrecvent la nivelul gleznei.

Modalitãþi terapeutice:– schimbarea stilului de viaþã;– identificarea ºi înlãturarea/tratarea facto-


� sulodexid 1 fiolã a 600 ULS pe zi (i.msau i.v.) timp de 20-30 de zile, apoi 4capsule a 250 ULS pe zi (2 capsule a 250ULS de 2 ori pe zi, între mesele prin-cipale) pânã la vindecarea ulcerului(C6), dupã care 2 capsule a 250 ULS pe zi(1 capsulã a 250 ULS de 2 ori pe zi), întremesele principale, tratament cronic (C5);




– scleroterapie;– laser vascular (PDL, Nd:YAG, diodã, etc.);– terapie endovenoasã;– tratament chirurgical *;– tratament topic **/pansament coloidal;– tratament antibiotic sistemic ***.


** Tratamentul topic va fi ales în concordanþã cu fiecarecaz în parte.

*** Tratamentul antibiotic local este de evitat datoritãriscului de selectare a unei flore bacteriene rezistente sauplurirezistente la antibiotice. Se recomandã administrarea deantibiotice sistemice în prezenþa unor dovezi bacteriologicede infecþie tisularã cu streptococ beta-hemolitic.

5. Patients with Chronic Venous Diseasein CEAP C5, C6 stages

Defining the type of patient according to theCEAP classification reviewed:C5 - cured venous ulcerC6 - active venous ulcer - lesion entirely

affecting the tegument, while the substance lossdoes not cure spontaneously. Most frequently itoccurs in the ankle area.

Therapy methods:– lifestyle changes;– identification and removal/treatment of


� sulodexide 1 vial x 600 LSU daily for 20-30 days, then 4 capsules x 250 LSU daily(2 capsules x 250 LSU, 2 times per day),between the main meals, until the ulcer(C6) is cured (C5), followed by 2capsules x 250 LSU daily (1 capsule x250 LSU, 2 times per day), between themain meals, chronic treatment;

� diosmin (450 mg) ± hesperidin (50 mg);� procyanidolic oligomers;� other phlebotonics;

– elastic contention depending on each case;– sclerotherapy;– vascular laser (PDL, Nd:YAG, diode, etc.);– endovenous therapy;– surgical treatment*.– topical treatment**/hydrocolloid dressing;– systemic antibiotic therapy***.


** The topical treatment shall be selected for each caseindividually.

*** Local antibiotic therapy should be avoided due to therisk of selecting a bacterial flora with resistance ormultiresistance to antibiotics. It is recommended to givesystemic antibiotics based on bacteriological evidence oftissue infections with beta-haemolytic Streptococcus.

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Conflict de interese Conflict of interestNEDECLARATE NONE DECLARED

Adresa de corespondenþã: Prof. Dr. Dumitru Alexandru TataruClinica Dermatovenerologie Cluj-Napoca, Str Clinicilor 3-5Email: [email protected]

Correspondance address: Prof. Dr. Dumitru Alexandru Tataru Dermatovenereology Clinic Cluj Napoca, 3-5 Clinics Email: [email protected]

3. Acute and chronic Venous Disease: current status and future directions (Journal of Vascular Surgery, vol 45, suppl 3,December 2007)

4. The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of theSociety for Vascular Surgery and the American Venous Forum (JOURNAL OF VASCULAR SURGERY, Volume 53,Number 16S, Gloviczki et al, Copyright © 2011 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.01.079)

5. Antithrombotic Therapy for Venous Thrombo-embolic Disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) (Clive Kearon, Susan R. Kahn, Giancarlo Agnelli, Samuel Goldhaber,Gary E. Raskob and Anthony J. Comerota. Chest 2008;133;454-545DOI 10.1378/chest.08-0658)

6. Updated terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensusdocument (JOURNAL OF VASCULAR SURGERY, Feb. 2009, Volume 49, Number 2, Eklöf et al)

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