CEAP Venous Classification Interpreter

The clinical class of chronic venous disease in the 2020 revision — with the C4 subclasses, the recurrence modifier the revision added, and the reason CEAP does not add up to anything.

Last updated 8 Oct 2026

CEAP clinical class, 2020 revision

C0 to C6 with subclasses and the r modifier

Clinical class — the most advanced sign in this limbOne limb at a time, and the most advanced sign present in it. The clinical class is a description of SIGNS; symptoms are recorded separately by the suffix s for symptomatic or a for asymptomatic, so C2s and C2a are both C2. A limb with varicose veins and an active ulcer is C6, and the class does not record that the varicosities are also there.

If the class is C4, which subclassIgnored unless the clinical class is C4. The 2020 update added C4c for corona phlebectatica and placed it last so that the existing C4a and C4b kept their meanings — a deliberate choice to preserve the previous version rather than renumber it. The order a, b, c is not an order of severity.

Recurrence after a previous interventionThe r modifier, new in the 2020 update, and it applies to exactly two classes: C2r for recurrent varicose veins and C6r for a recurrent active venous ulcer. There is no C4r and no C3r. Selecting recurrence with any other clinical class therefore changes nothing, which is the published instrument rather than an omission here.

C2 — varicose veinsExample

Varicose veins, not recurrent

The C component in the 2020 revision

This page implements the 2020 revision. Four things changed from the 2004 version: C4c was added for corona phlebectatica and placed last so C4a and C4b kept their meanings; the r modifier was added, giving C2r and C6r and nothing else; the secondary aetiology Es was split into Esi for intravenous causes and Ese for extravenous ones; and the eighteen numbered venous segments in the A component were replaced by anatomical abbreviations. A record written before 2020 cannot contain C4c, C2r or C6r, so the version belongs on the report.
Class	Definition	Changed in 2020?
C0	No visible or palpable signs of venous disease	No
C1	Telangiectasias or reticular veins	No
C2	Varicose veins	No
C2r	Recurrent varicose veins	NEW — the r modifier
C3	Oedema	No
C4a	Pigmentation or eczema	No
C4b	Lipodermatosclerosis or atrophie blanche	No
C4c	Corona phlebectatica	NEW subclass
C5	Healed venous ulcer	No
C6	Active venous ulcer	No
C6r	Recurrent active venous ulcer	NEW — the r modifier

The other three letters, which the C class is only a quarter of

A complete CEAP record looks like C2r,s Ep As,Ap Pr — a class, a symptom suffix, an aetiology, an anatomy and a pathophysiology. This page computes the C component, which is the part most often quoted alone and the part that gets a version wrong. The other three are listed so a reader can see what a bare C class is leaving out.
Component	Categories	What it records
E — aetiology	Ep primary, Es secondary (Esi intravenous, Ese extravenous), Ec congenital, En no cause identified	Why. The Esi and Ese split is new in 2020: Esi covers wall or valve damage from deep vein thrombosis, Ese covers heart failure, external compression and obesity
A — anatomy	As superficial, Ad deep, Ap perforator, An none identified, each with named segment abbreviations	Where. The 2020 update replaced the eighteen numbered segments with abbreviations of the vein names — GSVa and GSVb for great saphenous above and below the knee, SSV, AASV, POPV, PTV and so on
P — pathophysiology	Pr reflux, Po obstruction, Pr,o both, Pn none identified	What is wrong haemodynamically. A duplex finding, not a clinical one
Suffix	s symptomatic, a asymptomatic	Whether the limb hurts. C0s is a real and common record: no signs, demonstrable reflux, and a patient with aching and night cramps

A classification, a revision, and a number that does not exist

CEAP is a reporting standard for chronic venous disorders with four components — clinical, aetiological, anatomical and pathophysiological — and the clinical class is the part everybody quotes. C0 is no visible or palpable signs, C1 telangiectasias or reticular veins, C2 varicose veins, C3 oedema, C4 skin and subcutaneous changes, C5 a healed venous ulcer and C6 an active one. A limb takes the most advanced sign present; symptoms are recorded by a separate suffix, s or a, so a limb with no signs and real symptoms is C0s.

The version matters, and this page implements the 2020 revision. Four things changed from the 2004 version. A subclass C4c was added for corona phlebectatica, and placed after the existing C4a and C4b rather than renumbering them, so older records remain readable. A recurrence modifier was added, giving C2r for recurrent varicose veins and C6r for a recurrent active venous ulcer — and only those two; there is no C4r. The secondary aetiology Es was split into Esi for intravenous causes, chiefly deep vein thrombosis, and Ese for extravenous ones such as heart failure, external compression and obesity. And the eighteen numbered venous segments in the anatomical component were replaced by abbreviations of the vein names. A record written before 2020 cannot contain C4c, C2r or C6r, and a limb now recorded as C4c would have been C1 or C4a then, so the revision used belongs on the report alongside the class.

The thing most often got wrong about CEAP is that it is treated as a score. It is not, and there is nothing to add up. The classes are nominal descriptors of signs, C4b is not twice C2, and the 2020 update states in terms that the subclass order “does not indicate severity or prognosis”. Where a severity figure is genuinely wanted — to measure change over time, for instance — the Venous Clinical Severity Score is the separate ten-item weighted instrument built for that purpose, and the Villalta score is the separate instrument for post-thrombotic syndrome. Neither is reproduced in this corpus.

This category owns the limb and the named vessel. Venous thromboembolism belongs elsewhere: the Wells score for deep vein thrombosis and the Padua prediction score assess the risk and the probability of a clot, which is a different disease from chronic venous insufficiency even when the second follows the first. Chronic venous disease and deep vein thrombosis are linked — the 2020 update’s Esi class exists precisely to record a post-thrombotic aetiology — but they are different diseases assessed by different instruments, and a CEAP class says nothing about whether a clot is present. The version of the classification decides the answer before the limb does: the same limb is recorded differently under the 2004 and the 2020 revisions. Every class and criterion here is attributed to the body that publishes it, the published versions differ from one another, and your own service’s reporting standard takes precedence over all of them. This page computes a published index or places a finding in a published class. It recommends no action.

Frequently asked questions

What changed in the 2020 CEAP revision?

Four things. Subclass C4c was added for corona phlebectatica, placed last so that C4a and C4b kept their meanings. A recurrence modifier was added, giving C2r and C6r. The secondary aetiology Es was split into Esi for intravenous causes and Ese for extravenous ones. And the eighteen numbered venous segments in the anatomical component were replaced by anatomical abbreviations.

Is CEAP a score?

No, and treating it as one is the commonest error. The components are nominal descriptors with no points and no total, and the 2020 update states that the subclass order does not indicate severity or prognosis. C4b is not twice C2. If a severity measure is wanted, the Venous Clinical Severity Score is the separate instrument designed to measure change over time.

Which classes does the r modifier apply to?

Only C2 and C6, giving C2r for recurrent varicose veins and C6r for a recurrent active venous ulcer. There is no C4r and no C3r. Selecting recurrence with any other class on this page therefore leaves the class unchanged, which reflects the published instrument.

What is the difference between C5, C6 and C6r?

History, not size. C5 is a healed venous ulcer — the limb has ulcerated and the ulcer has closed. C6 is an active ulcer with no previous ulceration in that limb. C6r, new in 2020, is an active ulcer in a limb that has ulcerated before. None of the three says anything about how large or how severe the ulcer is.

Can a limb be C0 and still have venous disease?

Yes, and the classification is built for it. C0 means no visible or palpable signs, not no disease. A limb can be C0s — symptomatic with aching, heaviness or night cramps — with demonstrable reflux on duplex, which the P component records as Pr and the A component localises. That is why a full CEAP record carries all four letters rather than the C class alone.

Related calculators

References

Lurie F. 2020 update to the classification of chronic venous disorders. Phlebolymphology. 2020 — summarising Lurie F, Passman M, Meisner M, et al., J Vasc Surg Venous Lymphat Disord. 2020;8(3):342–52.
American Academy of Physical Medicine and Rehabilitation. Venous Insufficiency, Table 1: 2020 CEAP Classification. PM&R Knowledge NOW, 2023.
GPnotebook. Ankle brachial pressure index (ABPI). Oxford: GPnotebook, 2025.
American Academy of Family Physicians. Management of Lower Extremity Peripheral Artery Disease: Guidelines From the ACC/AHA. Am Fam Physician. 2025;112(5).
American Academy of Family Physicians. AHA Releases Recommendations on Ankle-Brachial Index Measurement and Interpretation. Am Fam Physician. 2013;88(12):866 — summarising Aboyans V, Criqui MH, Abraham P, et al., Circulation. 2012;126(24):2890–909.

Not medical advice. For healthcare professionals and education. Reference intervals vary by laboratory and assay — always use your own laboratory's. Never base a dose or a treatment decision on this page alone. Full disclaimer at calcengines.com/disclaimer/