A Systematic Review of the Effectiveness of Assessing Skin Changes for Chronic Venous Insufficiency in People With Dark Skin Tones and the Impact on the Patient Journey and Clinical Care.

Abstract

Aims: This review is aimed at systematically identifying, evaluating and synthesising the influence skin tone has on patient assessment and patient journey in people with chronic venous insufficiency.

Background: Chronic venous disease of the lower limb typically presents with cutaneous manifestations that differ across skin tones. However, its impact on patient assessment and patient journey is unknown.

Design: This systematic review and evidence synthesis were conducted following a protocol prospectively registered in PROSPERO (CRD42023459310) and reported using the PRISMA 2020 guideline.

Methods: Primary research studies, quality improvement projects or case reports published in English up to February 2025 were included. Screening, data extraction and quality appraisal were undertaken independently by two authors. As skin tone was rarely reported, ethnicity or race was used as a proxy, introducing a misclassification risk. Meta-analysis compared clinical classifications on CEAP, and other data were discussed narratively.

Data sources: Data sources include MedLine, Excerpta Medica Database (EMBASE), Cumulated Index of Nursing and Allied Health Literature (CINAHL), British Nursing Index (BNI), Scopus and registries of ongoing studies (ISRCTN registry and ClinicalTrials.gov).

Results: Twenty-two studies were included involving 111,090 individuals. Findings indicate that people of Black and Thai ethnicities may have pathophysiological changes associated with venous disease without some or all the clinical presentations of venous insufficiency. It is hypothesised that this contributes to people with dark skin tones not receiving timely vascular care and appropriate management in the early stages of venous hypertension. However, insufficient reporting on skin tone limits the interpretation of findings.Evidence suggests treatment disparities across ethnic groups, with people of Black ethnicity having higher treatment costs, more interventions and the least improvements following interventions. However, the contribution of skin tone and clinical presentation remains unclear due to a lack of qualitative data and the influence of other covariables, such as health-seeking behaviours and compression use.

Conclusions: Visible varicose veins appear to be unreliable indicators of venous disease, which may contribute to diagnostic challenges and health inequity. However, improved skin tone reporting is needed to enable clinical presentation to be considered independently of the social constructs of ethnicity.