An international survey on the interpretation of pigmentation using the C class of the Clinical, Etiological, Anatomical, Pathophysiological Classification

Skin changes over the gaiter area like pigmentation, lipodermatosclerosis and eczema are a clinical sign of advanced chronic venous disorder. This is documented as C₄ in the Clinical, Etiological, Anatomical, Pathophysio logical (CEAP) classification. The hypothesis was that there is great variability whether skin changes are recorded as early or advanced disease. The aim was to evaluate different patterns of skin changes by delegates at 3 international venous conferences. Seven high-definition, A4-sized, color photographs were taken of untreated legs with skin changes from patients attending a public hospital venous clinic. They all had venous disease confirmed on duplex with deep or superficial vein reflux >0.5 s. The photographs were displayed and a questionnaire was provided. Delegates familiar with CEAP were asked to choose from 3 C class options for each photograph. The responses were summarized by grouping them into mild (C_0-3) and severe (C_4-6). A total of 117 delegates completed the questionnaire from 30 countries. A percentage of 60 had practiced phlebology >10 years. The percentages of responders scoring mild (C_0-3) and severe disease (C_4-6) were: mild/severe=3/96 (photo 1), 65/33 (photo 2), 31/67 (photo 3), 56/34 (photo 4), 74/21 (photo 5), 89/10 (photo 6) and 37/59 (photo 7). The median percentage measure of agreement was 36.8 [95% confidence interval (CI): 24.8- 48.9]. The range was 23.2 (95% CI: 10.5-36.0) to 94.8 (95% CI: 90.7-98.9), P<0.001/image, Fisher exact test). This indicates a significant difference of opinion between the appearances of mild and severe clinical disease. Clinical decisions using the C class as a sign of advanced disease may be unreliable if used alone for recording severity, grouping patients or rationing treatment.