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

Aims: To systematically identify, evaluate and synthesise 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, it’s impact on patient assessment and patient journey is unknown. Design: This systematic review and evidence synthesis was 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 were used as a proxy, introducing a misclassification risk. Meta-analysis compared clinical classifications on CEAP and other data were discussed narratively. Data sources: 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, ClinicalTrials.gov) Results: 22 studies were included involving 111,090 individuals. Findings indicate people from Black and Thai ethnicities may have pathophysiological changes associated with venous disease without some or all the clinical presentations of venous insufficiency. It’s 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 interpretation of findings. Evidence suggests treatment disparities across ethnic groups, with people from 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 lack of qualitative data and the influence of other co-variables, 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 to the social constructs of ethnicity.