What's new in the 2020 update of the CEAP classification system of chronic venous disease?

The aim of the 2020 update of the CEAP (Clinical-Etiology-Anatomy-Pathophysiology) classification is provide the reproducibility of clinical findings between physicians, enable comparison of old and new versions of the CEAP classification, incorporate new evidence- based knowledge into the classification, and provide a balance between simple practical use and highly specific and detailed description of patient with chronic venous disease (CVD) in clinical and other studies. Clinical (C) classification remained unchanged and clinical definitions of all seven classes C0-C6 have been preserved. Class C4 is newly divided into three subclasses: C4a - pigmentation or eczema, C4b - lipodermatosclerosis or atrophie blanche and corona phlebectatica as the C4c clinical subclass has been added. Classes C2 (varicose veins) and C6 (active venous ulcer) are divided into subclasses C2R - recurrent varicose veins and C6R - recurrent active venous ulcer. Etiological (E) classification has not changed, more information on the subgroups has been recommended, resulting in a clearer description of each E subclass. ES is subcategorized to recognize intravenous secondary causes of venous disease (ESI), which is defined as any intravenous condition causing venous wall and/or valve damage; and extravenous secondary causes (ESE), in which case there is no venous wall or valve damage, yet symptoms are present owing to a condition affecting venous hemodynamics either locally or systemically. No cause identified category (EN) is defined of exclusion. The EN descriptor should be present when no other venous etiology (EC, EP, ESI or ESE) is found, yet there are clinical signs and symptoms that can be consistent with those typically associated with venous disease. In the Anatomical (A) classification anatomic abbreviations are now used instead of numbers of the venous segments. Pathophysiological (P) classification has not changed and the basic designation still includes four pathophysiological categories - reflux (PR), obstruction (PO), reflux and obstruction (PR/O), no venous pathophysiology (PN) with the addition of any (one or more) of named specific A anatomic venous segments according to the newly introduced abbreviations.