Once reserved for vascular surgeons, vein treatments are moving more and more into dermatology and aesthetic practices. One of the reasons is that visible veins are often viewed as a cosmetic concern. While physicians who are versed in injectables and laser treatments have the skills needed to treat visible veins effectively, in order to provide optimal results they must be aware that unsightly spider veins on the legs are often a symptom of deeper issues.
Spider veins—with the exception of the very tiny red ones—always have a source,” says Ronald Bush, MD, FACS, of The Vein Center at Water’s Edge Dermatology with multiple locations in Florida. “They are a symptom of cutaneous venous hypertension, which means that there is a higher source of pressure underneath the dermal layer causing these veins to dilate. It can be a reticular vein; it can be a perforator; or it can be a branch off of the greater saphenous vein.”
One of the key tools used to identify underlying vascular concerns is the duplex ultrasound. “You can use a VeinLite to see the reticular vein, and 80% of the time that might be enough, but you really want to see where that reticular vein comes from and shut that off too. You can only see this with an ultrasound,” says Dr. Bush.
To determine what type of diagnostic testing is necessary, Robert A. Weiss, MD, founder of MD Laser, Skin & Vein in Hunt Valley, Maryland, starts with a patient history. “We try to understand if there is a family history of varicose veins, which puts us on the lookout for larger veins,” he says. “After taking the history, we look at the patient’s legs. If she has any larger varicose veins—bigger than 3mm—on the medial part of the leg, then typically we do a full ultrasound of the superficial venous system. If we don’t see any varicosity and it’s just a history of spider veins, then we’re less likely to do further diagnostic evaluation before treating the spider veins.”
Changing the patient’s position and using proper lighting can help identify underlying concerns that would necessitate an ultrasound. “If you look carefully at the patient’s legs while she is standing, you can see some of the bulging veins in the area of the spider veins,” says Mitchel P. Goldman, MD, of Cosmetic Laser Dermatology in San Diego. “With the patient in the prone position, you can see the blue/green reticular veins that feed into the telangiectasia.” He cautions that bright lights can obscure the blue feeding veins, so you may need to turn the lights down to get a better view of the underlying vasculature.
Once the patient has been diagnosed, treatment should begin with the largest veins moving outward to the superficial spider veins. “If we see on the ultrasound that the main trunk of the venous system—the great saphenous vein—is enlarged and leaky, then we will go ahead and do endovenous laser ablation,” says Dr. Weiss. “If it’s just one or two leaky branches coming out but the great saphenous vein looks fine, then we’ll just do sclerotherapy of those smaller branches.”
In addition to endovenous laser ablation, also known as CTEV, physicians can use radiofrequency-based ablation (VNUS Closure) to seal off the larger great saphenous vein. “By using the laser or radiofrequency fiber, the procedure can be performed entirely under local anesthesia, and patients literally can get up, walk out of your office, and jog or play tennis the next day,” says Dr. Goldman.
“For smaller veins the size of your fingers, you can perform ambulatory phlebectomy, which was developed by a Swiss dermatologist named Robert Muller in 1958,” he continues. “You can do sclerotherapy on those veins as well, but they have a higher likelihood of reoccurring.”
Dr. Goldman recommends reserving sclerotherapy for veins that are 5mm in diameter—or about the size of a pencil—and smaller. There are three main sclerosants used today: glycerin, polidocanol (brand name Asclera) and sodium tetradecyl sulfate (brand name Sotradecol).
“The key part of sclerotherapy is matching the concentration of the solution to the size of the vein,” says Dr. Goldman. “Essentially, the really tiny veins are best treated with a glycerin solution. Larger veins are treated with either sodium tetradecyl sulfate or polidocanol. Varying the concentration to the size of the vessel will yield the best effect. By foaming the sclerosant with room air, you can make it even stronger.”
Dr. Bush uses liquid sclerotherapy—either sodium tetradecyl sulfate or polidocanol—for veins up to 2mm in diameter. “Foam sclerotherapy is the way to go for vessels 2mm or larger,” he says.
Dr. Weiss works with polidocanol almost exclusively. “We used to use sodium tetradecyl sulfate, but we find that Asclera is just so far superior that it has become the main agent that we are using,” he says.
“If the patient has a history of asthma, you have to use polidocanol,” says Dr. Bush, whose practice utilizes both Asclera and Sotradecol. “We do a spot test in two different areas. Whichever offers the best response in the patient is what we use. Overall, we tend to work with sodium tetradecyl sulfate more often because it is more cost effective and easier to dilute. It comes in 3%, whereas Asclera only comes in 1%. If you use it at the proper concentration, you won’t get staining.”
While administering sclerosants at their manufactured concentration will not harm the patient, it can cause erythema and irritation. By diluting the solutions to the minimum concentration needed for efficacy, physicians can deliver a more comfortable treatment with less postprocedure redness.
For smaller veins, Dr. Weiss dilutes the liquid Asclera to 0.25%. “This is very safe and adequate but Asclera is only sold in 0.5% and 1% concentrations, so we take it out of the 2ml container and dilute it 1:1 with normal saline,” he says.
Dr. Bush published a study online in Phlebology (October 12, 2016) that evaluated the ideal concentrations of sodium tetradecyl sulfate and polidocanol sclerotherapy for 0.8mm to 1mm leg veins. He found that the sodium tetradecyl sulfate 0.15% and polidocanol 0.31% are the best sclerosant concentrations for 0.8mm to 1mm leg telangiectasia. He also investigated the use of foam sclerosants at the same concentration for 2mm reticular veins and concluded that “sodium tetradecyl sulfate foam is comparable to polidocanol foam at these concentrations as well.”
Dr. Weiss uses foam sclerotherapy for reticular veins and larger telangiectasia. “We do three parts air to one part of solution, and then go back and forth with a Luer-lock adapter 10 to 20 times until it foams up,” he says.
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Risks and Adverse Events
The most serious complication of sclerotherapy is allergic anaphylaxis, which is extremely rare. Still, doctors who perform leg vein treatments should have an EpiPen in the office, says Dr. Bush.
Another rare but serious adverse event is skin ulceration. “It almost never happens. The ulcer is usually smaller than a dime and heals on its own,” says Dr. Goldman. “It occurs
if you inadvertently inject some of the solution into a nearby arterial.”
A more common but less serious complication is telangiectatic matting. “This also tends to resolve itself. If it doesn’t, that means you’ve missed one of the feeding veins and you need to go back and treat it,” says Dr. Goldman. “In some cases, you may get some pigmentation—a little brown staining along the course of the vein. Usually that goes away on its own as well. If not, it can be treated with a Q-switched alexandrite, Q-switched ruby or picosecond laser.”
You can reduce the risk of ulcerations by paying careful attention to your injection technique and clinical endpoints. “You want to do gentle injections and not force a lot of solution in there all at once,” says Dr. Bush. “Let it go in there gradually and clear the vein. Don’t be too forceful or it can go backward into the capillaries and the arterial, which will cause ulcerations.”
“If the patient complains of pain, you may be near an arterial so stop and move,” advises Dr. Weiss. “You don’t have to completely empty the syringe, just use enough to fill up the vein. What you will see is that all of the veins that were either blue or red are now clear because you have filled them with a clear solution or clear foam. That shows you where you’ve done the treatment and whether it’s been adequate.”
One of the most common mistakes he sees when training residents in sclerotherapy is incorrect placement of the needle. “When someone is learning, they often inject way too deep, way under the telangiectasia,” says Dr. Weiss. “To minimize that possibility, take the needle and bend it at a 45˚angle just before using it. This way, you’re much more likely to stay superficial and perpendicular with the vein rather than going right past it.”
To keep the needle in the correct plane, Dr. Weiss recommends using your non-dominant hand to steady the syringe. “You need to slide the whole syringe along your non-dominant hand, which is placed on the leg of the patient,” he says. “This allows you to make very fine movements and ensures that once you are in the vein, you don’t modify the position of the needle.”
To help him see the veins he is injecting, Dr. Weiss uses a head lamp with magnification and cross-polarized lighting (Syris Scientific). “The cross-polarizing filters stop all surface reflection, so you can see a possible entry point more easily,” he says. “There is also a device (called the AccuVein) that measures the infrared coming off the skin and projects it back in a color. That’s really good for reticular veins. You can see exactly where they are and start your puncture and cannulation of the vein with a great deal of precision.”
Following treatment, Dr. Bush has patients apply Dermica Cream. “The redness disappears within five to seven minutes,” he says. “We have them use the cream and wear compression garments for three to four days.”
Dr. Goldman has his patients wear compression garments for a full seven days, 24 hours a day. “The type I use have a 30mm to 40mm mercury compression at the ankle,” he says. “The stockings will not only decrease the diameter of the treated veins, but they will also decrease the diameter of any feeding veins and improve the circulation in the legs. By doing that, you eliminate any form of thrombosis, minimize the risk of pigmentation and reduce recurrence of the veins.”
If you are interested in adding or expanding your treatment options for visible veins, there are a number of training resources available. The American College of Phlebology (phlebology.org) offers training courses, as do the American Academy of Dermatology (aad.org) and the American Society for Dermatologic Surgery (asds.net). Drs. Goldman and Weiss co-authored a comprehensive textbook, Sclerotherapy Expert Consult (Elsevier), which includes instructional DVDs. This is just one of many textbooks on vein treatments available.
“It is a good idea to attend at least a few courses, and then observe someone who really knows what they’re doing as well,” says Dr. Weiss. “There is some art—as well as a lot of science—to vein treatments. There are little things that you can’t really read in a description and visualize. You need to see the procedures performed.”
Inga Hansen is the executive editor of MedEsthetics.
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