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Thrombophlebitis
This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review.
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Changes
Version 1.0.0, revision planned in 2009.
Last revised in February 2006
JulySeptember 2005 reviewed. Validated in December 2005 and issued in February 2006.
Previous changes
July 2005 updated to include prescribing information for compression stockings. Issued in
July 2005.
April 2002 reviewed. Validated in June 2002 and issued in July 2002.
February 1999 written. Validated in April 1999 and issued in May 1999.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 March 2007.
HTAs (Health Technology Assessments)
No new HTAs since 1 March 2007.
Economic appraisals
No new economic appraisals relevant to England since 1 March 2007.
Systematic reviews and meta-analyses
A new Cochrane review has been published since the last revision of this CKS topic.
Di Nisio, M., Middeldorp, S. and Wichers, I.M. (2007) Treatment for superficial thrombophlebitis
of the leg (Cochrane Review). The Cochrane Library. Issue 1. Chichester, UK: John Wiley & Sons,
Ltd. www.thecochranelibrary.com [Accessed: 19/03/2007]. [Free Full-text]
Primary evidence
No new high quality randomized controlled trials since 1 March 2007.
New policies
No new national policies or guidelines since 1 March 2007.
Treat pain with an oral nonsteroidal anti-inflammatory drug (NSAID), as their antiinflammatory effect is thought to be helpful.
If intolerant of NSAIDs, paracetamol is a suitable alternative painkiller.
This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review.
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Although there is no evidence for its use, some people may find local heat helpful (e.g. by
the application of a warm moist towel or flannel to the affected limb).
Consider prescribing a compression stocking if a leg vein is affected, as these are
thought to help reduce pain, improve venous blood flow, and reduce the chance of
thrombosis extending or recurring.
Advise leg elevation when resting if a leg vein is affected, as leg elevation is thought
to improve venous blood flow and reduce swelling.
Encourage people to keep mobile bed rest is not advised.
Anticoagulants are not usually indicated for superficial thrombophlebitis if deep vein
thrombosis is suspected, arrange for urgent referral.
Antibiotics are not indicated in aseptic superficial thrombophlebitis (which accounts
for most cases of superficial thrombophlebitis).
Consider the possibility of septic superficial thrombophlebitis if there is a break in
the skin (e.g. with intravenous cannulation or drug abuse) although it can occasionally
occur spontaneously.
o
Admission is generally required for antibiotic treatment.
o
Intravenous drug abusers may have unusual infections, including botulism, MRSA
(methicillin-resistant Staphylococcus aureus) and Streptococcus Group A, and
treatment of these people requires admission or specialist advice.
o
Mild superficial thrombophlebitis can be treated in primary care with flucloxacillin, or a
macrolide (erythromycin or clarithromycin). Note: antibiotics may not be necessary for
very mild cases.
Compression stockings
This PRODIGY guidance topic is obsolete and has been replaced by a CKS Topic Review.
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Antibiotics
Always admit:
o
If there is suppurative thrombophlebitis
o
If there is clinical evidence of a deep vein thrombosis (DVT)
o
If chest pain or dyspnoea are present, as either may indicate pulmonary embolism
Admit or arrange urgent hospital assessment if DVT is suspected. Particularly
suspect DVT if:
o
Thrombophlebitis is mid-thigh extending towards the sapheno-femoral junction. Duplex
scanning is advisable to determine the extent of thrombus propagation.
o
If other risk factors are present, such as past history of DVT, bilateral involvement,
recent bed rest or immobilization, or involvement of a non-varicose vein (see What are
the risk factors?).
Admit people with septic thrombophlebitis unless mild.
o
Particularly consider the possibility of septic thrombophlebitis if there is a break in the
skin (e.g. with intravenous cannulation or drug abuse).
o
There is no guidance in the literature regarding criteria for admission. People who are
systemically unwell or with enlarged lymph nodes or tracking should always be
admitted but it should be remembered that even people with mild symptoms can
deteriorate rapidly.
o
Use clinical judgement, with special caution in high risk groups such as drug addicts
who may have unusual infections, including botulism, MRSA (methicillin-resistant
Staphylococcus aureus) and Streptococcus Group A.
Consider referral for varicose vein surgery if symptoms persist or if extensive
varicosities are present.
Investigate?
Follow-up advice
Prescriptions
Ibuprofen tablets: 400mg three times a day
Age from 16 years onwards
Ibuprofen 400mg tablets. Take one tablet three times a day. Supply 42 tablets.
NHS Cost 1.65
OTC Cost 2.91
Licensed use: yes
Ibuprofen 400mg tablets. Take one tablet four times a day. Supply 56 tablets.
NHS Cost 2.21
OTC Cost 3.89
Licensed use: yes
Diclofenac sodium 25mg gastro-resistant tablets. Take one tablet three times a day. Supply
42 tablets.
NHS Cost 1.16
Licensed use: yes
Diclofenac sodium 50mg gastro-resistant tablets. Take one tablet twice a day. Supply 28
tablets.
NHS Cost 0.96
Licensed use: yes
Diclofenac sodium 50mg gastro-resistant tablets. Take one tablet three times a day. Supply
42 tablets.
NHS Cost 1.44
Licensed use: yes
Naproxen 250mg tablets. Take one tablet twice a day. Supply 28 tablets.
NHS Cost 1.96
Licensed use: yes
Naproxen 500mg tablets. Take one tablet twice a day. Supply 28 tablets.
NHS Cost 2.19
Licensed use: yes
Paracetamol 500mg tablets. Take two tablets every 4 to 6 hours when required for pain
relief. Maximum of 8 tablets in 24 hours. Supply 100 tablets.
NHS Cost 1.82
OTC Cost 3.21
Licensed use: yes
Patient Information: You may find that your paracetamol works best if you take it regularly
four times a day to start with.
Compression hosiery class I below knee stocking circular knit standard stock size. One pair
of circular knit, below-knee class I compression stockings to be measured and fitted in the
pharmacy. Supply 2 single stockings.
NHS Cost 6.41
OTC Cost 15.06
Licensed use: yes
Patient Information: You can chose to have the following types of stockings: stockings with
a closed heel and toe, stockings with an open toe. Put the stocking(s) on first thing in the
morning and remove before you go to bed.
Compression hosiery class I thigh length stocking circular knit standard stock size. One pair
of circular knit, thigh length class I compression stockings to be measured and fitted in the
pharmacy. Supply 2 single stockings.
NHS Cost 7.02
OTC Cost 16.50
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Suspender belt
Age from 16 years onwards
Flucloxacillin 500mg capsules. Take one capsule four times a day for 7 days. Supply 28
capsules.
NHS Cost 6.52
Licensed use: yes
Erythromycin 250mg gastro-resistant tablets. Take two tablets four times a day for 7 days.
Supply 56 tablets.
NHS Cost 6.44
Licensed use: yes
Clarithromycin 500mg tablets. Take one tablet twice a day for 7 days. Supply 14 tablets.
NHS Cost 21.44
Licensed use: yes
Drug rationale
Drugs not included
Anticoagulants are not usually indicated for superficial thrombophlebitis. If deep vein
thrombosis is suspected, arrange for urgent referral.
Antiplatelets: because superficial thrombophlebitis is primarily due to inflammation and
fibrin clot there is no evidence of value for antiplatelet drugs [Feied and Handler, 2004b].
Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are not recommended
because there are no good quality trials that compare the efficacy of topical NSAIDs with the
same NSAID given orally or with paracetamol [Moore et al, 1998; Heyneman et al, 2000;
Gotzsche, 2005].
NSAIDs (other than ibuprofen, diclofenac, and naproxen) that are associated with a
higher risk of gastrointestinal adverse events or that are not licensed for general
musculoskeletal pain and inflammation are not recommended [CSM, 1994; Henry et al,
1996; Hernndez-Diaz and Rodriguez, 2000].
NSAID modified-release preparations: improvement in efficacy and reduction in adverse
events have not been shown [Eccles et al, 1998]. Modified-release formulations are also
relatively expensive.
Cyclo-oxygenase 2 (COX-2) selective inhibitors are not recommended. Standard
NSAIDs have a good balance of efficacy versus adverse effects. The evidence suggests that
selective COX-2 inhibitors, as a class, may cause an increased risk of thrombotic events
(e.g. myocardial infarction and stroke) compared with placebo and some NSAIDs, and the
risk may increase with dose and duration of exposure [CSM, 2005].
Topical heparinoid preparations: there are no good quality controlled trials of topical
heparinoid preparations. The trials that there have been were poorly designed and the
patient numbers were generally small.
Drugs included
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To alleviate symptoms
To identify and manage complications (e.g. deep vein thrombosis)
Background information
What is it?
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The most important risk factors for developing superficial thrombophlebitis are a past
history of:
o
Superficial thrombophlebitis
o
Deep vein thrombosis
o
Pulmonary embolism
Other risk factors include a history of either primary or secondary hypercoagulable states.
Hypercoaguable states
Examples of primary hypercoagulable states are [Samlaska and James, 1990a; Feied
and Handler, 2004a]:
o
Antithrombin and heparin cofactor II deficiencies
o
Protein C and Protein S deficiencies
o
Factor V Leiden
o
Disorders of the fibrinolytic system
o
Dysfibrinogenemias
o
Lupus anticoagulant and anticardiolipin antibody syndrome
o
Prothrombin gene variant
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o
Recent surgery
o
Obesity
o
Long haul flight
o
Advanced age
Intravenous therapy and drug abuse:
o
Intravenous catheters
o
Intravenous solutions
o
Sclerotherapy
o
Intravenous drug misuse:
Street drugs are often cut with substances that promote thrombosis (e.g. lactose,
sucrose, dextrose). Cocaine in particular seems to promote thrombosis [Samlaska
and James, 1990b].
Endothelial dysfunction. There are three diseases that are due to endothelial dysfunction
caused by primary immunologic mechanisms or direct tissue injury [Samlaska and James,
1990b; Lehner, 2003; Burns, 2004; Johnson, 2004]:
o
Behet's syndrome is a rare condition in which there is a classical triad of oral
ulceration. genital ulceration, and uveitis. Vascular complications include superficial
migratory thrombophlebitis, deep vein thrombosis, and superior and inferior vena cava
thrombosis [Lehner, 2003].
o
Buerger's disease (thromboangiitis obliterans) is a rare condition in which gangrene
occurs due to inflammation and thrombosis of the arteries and veins in the hands and
feet. It most commonly occurs in young men who smoke cigarettes. Small studies have
described superficial migratory thrombophlebitis in 2766% of people with Buerger's
disease.
o
Mondor disease is a rare condition characterized by thrombophlebitis of the
subcutaneous veins of the anterior chest wall, in particular the lateral thoracic vein, the
thoracoepigastric vein, and the superior epigastric vein. Two thirds of affected people
are women. It is usually a benign condition that spontaneously resolves over 2
4 weeks, but it has been associated with breast cancer.
Infectious disease:
o
Septic thrombophlebitis
o
Psittacosis
o
Secondary syphilis
[Samlaska and James, 1990b; DePalma and Johnson, 2000; Schonauer et al, 2003; Feied and
Handler, 2004a; Leon et al, 2005]
[Feied and Handler, 2004a; Feied and Handler, 2004b; Johnson, 2004]
Examination
Pain, tenderness, warmth, and redness along the course of a vein are diagnostic
features [Messmore et al, 1991].
The thrombosed veins feel like cords (knots) or a chain of nodules [Messmore et al, 1991].
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Fever, lymphangitis, and signs of systemic upset (especially if septic thrombophlebitis) may
also be present.
Redness and oedema may extend for some distance into surrounding tissue making
distinction from infection difficult [Mortimer and Burnand, 2004].
Thrombophlebitis in a varicose vein may extend up and down the saphenous vein or it may
remain localized in a cluster of tributary varicosities [Johnson, 2004].
Always examine for a deep vein thrombosis. Clinical features may be absent or include
one or more of the following:
o
Swelling of the calf or thigh in one leg
o
Pain and tenderness along the line of the deep venous system
o
Low-grade pyrexia (uncommon)
o
Increased skin temperature
o
Distension of superficial veins
o
Colour change (red or purple)
In septic superficial thrombophlebitis the initial site of infection may be a well-localized
area of tenderness and redness. There may be lymphangitis, lymphadenopathy, localized
cellulitis, inflammation along the course of a vein, and systemic upset (e.g. fever).
Intravenous drug misusers often have a localized area of cellulitis or frank abscesses at the
site of the injection [Samlaska and James, 1990b; Feied and Handler, 2004b]. In
suppurative superficial thrombophlebitis, pus can be expressed from a vein and there is
often septicaemia [Feied and Handler, 2004b].
Investigations
The diagnosis of thrombophlebitis is usually made through history and examination alone
[Messmore et al, 1991].
If superficial thrombophlebitis occurs in a vein that is not varicose and there is no obvious
predisposing cause, suspect an underlying condition that predisposes to thrombophlebitis,
particularly if episodes are recurrent or occur at an early age [Mottahedeh and Da Silva,
2003; Leon et al, 2005].
o
Consider a primary hypercoagulable state, particularly if there is a family history of
thrombosis or if the affected vein is non varicose. Consider seeking advice from a
haematologist on appropriate tests to carry out and their interpretation.
o
If a secondary hypercoagulable state is suspected (e.g. possible cancer) arrange
appropriate investigations.
Cellulitis
Deep vein thrombosis (DVT)
Tendonitis
Soft tissue trauma
Cutaneous polyarteritis nodosa
Sarcoidal granuloma
Erythema nodosum
Lymphangitis
Neuritis
Ruptured medial head of gastrocnemius
[Samlaska and James, 1990b; Wasserman et al, 1997; Belcaro et al, 1999; Johnson, 2004]
Superficial thrombophlebitis can extend through perforating veins to involve the adjacent
deep veins. In people with hypercoaguable states, deep vein thrombosis (DVT) may also be
present at other sites in the same or opposite leg [Feied and Handler, 2004a].
Studies in people with superficial thrombophlebitis have found a frequency of deep vein
involvement (detected by duplex ultrasound scanning) ranging from 657%. Many of these
studies were in people who had been referred to vascular laboratories [Bergqvist and
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Jaroszewski, 1986; Jorgensen et al, 1993; Bendick et al, 1995; Chengelis et al, 1996;
Blumenberg et al, 1998].
These figures seem alarming but it should be remembered that the incidence in UK general
practice is likely to be much lower.
Pulmonary embolism
Pulmonary embolism (PE) has been reported in people with superficial thrombophlebitis.
Usually the embolus has resulted from a co-existing deep vein thrombosis (DVT), but there
is some evidence that thrombus from the superficial veins can embolize to the lungs with no
obvious deep vein involvement.
The incidence of PE in people with superficial thrombophlebitis presenting in UK general
practice is unknown.
The frequency of PE has been reported as 033%.
o
One study reported a clinical incidence of less than 1% in 232 people referred to a
vascular laboratory [Blumenberg et al, 1998].
o
Higher figures have been reported from studies that have diagnosed PE by lung
perfusion scanning (e.g. 4% in a study of 186 people with superficial thrombophlebitis
who had been referred for duplex scanning) [Lutter et al, 1991].
o
One small study (21 people) with superficial thrombophlebitis of the proximal greater
saphenous vein found that 7 people (33%) had evidence of a PE detected by perfusion
lung scanning, although only one person had clinical symptoms of a PE [Verlato et al,
1999].
Minor complications
[Feied and Handler, 2004b; Johnson, 2004; Scheld and Sande, 2005]
Prognosis
Aseptic superficial thrombophlebitis
Management issues
When should I consider the possibility of a DVT?
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DVT by extension to the femoral vein through the sapheno-femoral junction [Lutter et al,
1991; Chengelis et al, 1996].
There is some evidence from small studies that a DVT is more likely if the person
does not have varicose veins. One study of 58 people (population not defined) with
superficial thrombophlebitis of the lower legs found that the prevalence of DVT in people
without varicose veins was 44% and with varicose veins was 2.6% [Bergqvist and
Jaroszewski, 1986]. A study of 60 people attending a private outpatient clinic found an
incidence of DVT in 8% of those with varicose veins but in 33% of those with no varicose
veins [Gorty et al, 2004].
Other risk factors that have been associated with DVT or PE in people with
superficial thrombophlebitis are:
o
Past history of DVT or venous thromboembolism
o
Bilateral involvement
o
Bed rest/recent immobilization
o
Male sex
o
Age greater than 60 years
o
Systemic infection
Co-existent malignancy, pregnancy, and taking combined oral contraception
should also be considered to be significant risk factors. We could find no studies that
have investigated the incidence of DVT specifically in people who have superficial
thrombophlebitis and one of these factors, but there is evidence from other populations that
they are associated with an increased risk of DVT.
[Lutter et al, 1991; Bounameaux and Reber-Wasem, 1997; Schonauer et al, 2003]
Always admit:
o
If there is suppurative thrombophlebitis, as the infected vein must be removed
surgically [Feied and Handler, 2004b; Scheld and Sande, 2005].
o
If there is clinical evidence of a deep vein thrombosis (DVT).
o
If chest pain or dyspnoea are present, as either may indicate pulmonary embolism.
Admit or arrange urgent hospital assessment if DVT is suspected. Particularly
suspect DVT if:
o
Thrombophlebitis is mid-thigh extending towards the sapheno-femoral junction. Duplex
scanning is advisable to determine the extent of thrombus propagation [Mottahedeh
and Da Silva, 2003; Leon et al, 2005].
o
If other risk factors are present, such as past history of DVT or venous
thromboembolism, bilateral involvement, recent bed rest or immobilization, or
involvement of a non-varicose vein (see What are the risk factors?).
There is conflicting opinion over whether DVT needs to be excluded in people with
superficial thrombophlebitis at sites other than the mid-thigh. Local guidelines should
be followed where they exist and clinical judgement used.
Septic thrombophlebitis will require admission for antibiotic treatment unless the
infection is mild.
o
Particularly consider the possibility of septic thrombophlebitis if there is a break in the
skin (e.g. with intravenous cannulation or drug abuse).
o
There is no guidance in the literature regarding criteria for admission. People who are
systemically unwell or with enlarged lymph nodes or tracking should always be
admitted but it should be remembered that even people with mild symptoms can
deteriorate rapidly.
o
Use clinical judgement, with special caution in high risk groups such as drug addicts
who may have unusual infections, including botulism, MRSA (methicillin-resistant
Staphylococcus aureus) and Streptococcus Group A.
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There is a lack of data on how effective any of the medical treatments are for superficial
thrombophlebitis (see Supporting evidence) [Leon et al, 2005].
Uncomplicated superficial thrombophlebitis affecting venous tributaries is usually
treated symptomatically with:
o
Nonsteroidal anti-inflammatory drugs (NSAIDs)
o
Compression stockings on the legs
o
Paracetamol is an alternative analgesic for people who are intolerant of NSAIDs
Local heat. The use of local heat (e.g. a warm moist towel or flannel to the affected limb)
has been standard practice for years. Although there is no evidence for its use, some people
may find it helpful.
Treatment should continue until pain and redness have settled (usually within 26 weeks,
although the thrombosed vein may be palpable and tender for months).
Anticoagulants are not usually indicated for superficial thrombophlebitis. If deep vein
thrombosis is suspected, arrange for urgent referral. The use of anticoagulants for
thrombophlebitis are not recommended in primary care.
Encourage use of the affected arm or leg, and to continue usual daily activities. Leg
elevation is thought to improve venous blood flow and to reduce swelling. Bed rest is not
advised, as bed rest may increase the risk of deep vein thrombosis.
Consider referral for varicose vein surgery if extensive varicosities are present or if
symptoms persist, as ligation and stripping of the affected veins may be indicated
[Belcaro et al, 1999; Johnson, 2004]. Follow local guidelines and use clinical judgement.
Advise against standing for long periods of time and inactivity [Johnson, 2004].
Compression stockings. There is no evidence for the use of compression stockings and
there is conflicting advice in the literature. Follow local guidelines where they exist and use
clinical judgement. It is important to exclude arterial insufficiency. As thrombophlebitis is
quite a painful condition many people will find the use of Class 2 compression stockings
almost impossible and Class 1 stockings are a practical alternative.
Medicines management
What are the adverse effects of NSAIDS?
Paracetamol
Paracetamol should be taken at regular intervals, rather than on an 'as required' basis.
Flucloxacillin
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Macrolides
Supporting evidence
To our knowledge, no adequately designed comparative trials have been performed addressing
the relative efficacy and safety of the various medical treatment options available for
thrombophlebitis.
The rationale for treating superficial thrombophlebitis with heparin or low molecular weight
heparin (LMWH) is the neutralization and inhibition of thrombin generation and the
prevention of thrombus extension and recurrence of thrombus [Kalodiki and Nicolaides,
2002]. Anticoagulation is not recommended unless the thrombus is large and extending
toward the sapheno-femoral junction (a relatively rare situation) [Wakefield, 1994].
One pilot double-blind randomized trial (n = 427) compared two different dosage regimens
of enoxaparin (a LMWH), tenoxicam (a nonsteroidal anti-inflammatory drug), and placebo
for 10 days in people with superficial thrombophlebitis [Superficial Thrombophlebitis Treated
By Enoxaparin Study Group, 2003]. All groups were also treated with compression
stockings. The primary outcome measure was deep venous thrombosis (defined as deep
vein thrombosis, symptomatic pulmonary embolism, or both). The secondary outcome
measure was the combined endpoint of deep venous thrombosis and/or superficial vein
thrombosis recurrence or proximal extension.
o
By day 12, there was no statistically significant difference in the primary outcome
measure in any active treatment group compared with placebo. However, the incidence
of the secondary outcome measure was significantly less in all active treatment groups
compared with placebo (9.3% and 6.9% in the enoxaparin groups, 14.9% in the
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tenoxicam group, and 30.6% in the placebo group). However, the difference in
incidence was mainly due to a reduction in the incidence of superficial vein events.
o
At 3-month follow-up, there was still a statistically significant difference in active
treatment groups compared with placebo.
o
There were no statistically significant differences in outcomes between the enoxaparin
and tenoxicam treated groups.
A small open randomized trial (n = 60) compared high-dose heparin (12,500 IU) with lowdose heparin (5000 IU) treatment for 4 weeks in people with acute thrombophlebitis of the
great saphenous vein in the thigh [Marchiori et al, 2002]. The outcome measure was the
incidence of thromboembolic complications (defined as asymptomatic deep vein thrombosis
and/or symptomatic thromboembolic events).
o
After 6-months' follow-up, the rate of thromboembolic complications was 20% (95% CI
7.7 to 38.6%) in the in the low-dose group and 3.3% (95% CI 0.07 to 17.2%) in the
high-dose group. Overall, there were 26 thromboembolic complications, but 19 of these
were superficial vein events (extension or recurrence of superficial thrombophlebitis).
o
Although the results suggest that high-dose heparin may be beneficial compared with
low-dose heparin, the confidence intervals overlapped and the results were of
borderline statistical significance (p = 0.05) using a one-sided test and non-significant
using a two-sided test (p = 0.10).
There are no good quality randomized controlled trials to support the use of compression
stockings in people with thrombophlebitis. However, it is standard practice to use them in
people with superficial thrombophlebitis, as it is thought that they reduce pain, improve
venous blood flow, and reduce the risk of further thrombosis. Which class of stocking or
whether a full leg or below knee stocking should be used is not stated in the literature
[Messmore et al, 1991; Wakefield, 1994].
We found one open randomized trial (n = 562) that assessed the efficacy of elasticated
stockings (class of stocking not specified) in people with superficial thrombophlebitis
affecting varicose veins [Belcaro et al, 1999]. In this study, one group used elasticated
stockings, a second group used elasticated stockings and had early surgery (simple ligation
or complete stripping), and a third group used elasticated stockings with prophylatic
anticoagulation and delayed surgery.
o
Over a 6-month period, the incidence of deep vein thrombosis ranged from 3.15.3%,
with no statistically significant difference among the treatment groups.
o
Those treated with compression alone or compression plus saphenous ligation were
more likely to have extension of the superficial thrombophlebitis at 36 months' followup.
There are no trials that assess the efficacy of hot compresses or the application of heat to
treat thrombophlebitis. Hot compresses are recommended on the basis of expert opinion
[Messmore et al, 1991; Wakefield, 1994].
There is no evidence for the use of antibiotics for the treatment of aseptic superficial
thrombophlebitis. If septic superficial thrombophlebitis is suspected then admission for
antibiotic treatment is generally advised, unless the infection is mild. See How should I
manage septic superficial thrombophlebitis?
References
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All references with links to [Free Full-text] are freely available online to users in
England and Wales. This includes the full text of Department of Health papers and Cochrane
Library reviews.
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thrombophlebitis. A comparative trial between placebo, Hirudoid cream and piroxicam gel.
Annales Chirurgiae et Gynaecologiae 79(2), 92-96.
Blumenberg, R.M., Barton, E., Gelfand, M.L. et al. (1998) Occult deep venous thrombosis
complicating superficial thrombophlebitis. Journal of Vascular Surgery 27(2), 338-343.
Bounameaux, H. and Reber-Wasem, M.A. (1997) Superficial thrombophlebitis and deep vein
thrombosis. A controversial association. Archives of Internal Medicine 157(16), 1822-1824.
Burns, D.A (2004) The breast. In: Burns, D.A, Breathnach, S., Cox, N. and Griffiths, C.
(Eds.) Rook's textbook of dermatology. 7th edn. Oxford: Blackwell Science. 67.15
Chengelis, D.L., Bendick, P.J., Glover, J.L. et al. (1996) Progression of superficial venous
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