Dermatologists we are frequently asked by their patients to help clear their varicose and spider veins by a technique called sclerotherapy. In North America over the last 30 years public interest in this field has dramatically increased. Sclerotherapy has become a common office procedure. The three basic reasons patients may request sclerotherapy is to improve the cosmetic appearance of the legs, to relieve pain and discomfort, and to help prevent the complications of long standing varicose veins. Sclerotherapy is not a curative treatment, but will assist in controlling the patient’s venous disease and help to maintain cosmetic improvement. For patients who simply present with spider veins a series of sclerotherapy treatments may clear the unsightly veins completely. There are many cases however, where patients have larger veins called reticular or varicose veins. These veins require treatment prior to treating the spider veins. In many instances, sclerotherapy will be a good choice of treatment for these larger veins as well. Some patients have more complex veins and require additional or other forms of treatment such as surgical stripping, ambulatory phlebectomy, EVLT (endovenous laser therapy) , or traditional laser therapy. Most patients who come to the dermatologist have reticular and spider veins or only.
What is sclerotherapy?
Sclerotherapy is the treatment of varicose and spider veins by injection of various chemical agents into the vein causing its destruction and disappearance. A tiny needle is used to inject a solution that irritates the internal lining of the vein causing it to collapse and stick together. The insertion of the needle may sting a bit, but most injections are hardly felt at all. The injected solution can sting slightly for short periods of time. Over a period of weeks the vessel shrinks into a fibrous cord that fades from view, eventually becoming barely or not at all visible. Depending on its size, a single blood vessel may have to be injected more than once. Because larger reticular and varicose veins often underlie spider veins these vessels must be treated as well. There are a variety of solutions available, but the most commonly used solution is Sclerodex® (a combination of salt and sugar (dextrose)). In more resistant cases stronger sclerosing solutions are used such as Sclerodine®, Tromboject®, and Saliject®.
What causes varicose and spider veins ?
Heredity is the major contributing factor causing varicose and spider veins. It is more common in women. Up to 50% of North American women may be affected. Hormonal factors including pregnancy, menopause, the use of birth control pills, and estrogens, may affect the development of venous disease. It is very common for pregnant women to develop varicose veins. Other predisposing factors include aging, standing occupations, obesity, and leg trauma or injury. Functionally, the main abnormality in these veins are absent, damaged, or nonfunctioning valves. Normal properly functioning valves cause the blood to flow in one direction back to the heart. When veins lack intact functioning valves the blood has more difficulty travelling back to the heart, and causes the blood in the veins to pool or collect by gravity in the lower legs. This causes an increased pressure in the veins, which in turn causes the veins to dilate (enlarge).
What if I do not treat my varicose and spider veins?
Vein disease is progressive which if left untreated is likely to become worse with time. This may lead to more spider veins resulting in a more extensive cosmetic problem. Untreated reticular and varicose veins may lead to more leg tiredness, heaviness, discomfort, throbbing, restlessness, or swelling. In patients who have more extensive venous disease more serious complications may develop such as superficial or deep vein thrombosis (phlebitis), eczema (dermatitis), and skin ulcers (open sores) which may be difficult to heal, and once healed will likely lead to scarring.
What to expect at your office visit ?
In your initial evaluation the physician or one of the office staff will take a medical history with particular attention to details about venous disease in you and your family, The history will include a discussion of your reasons for seeking treatment, and review any symptoms of venous disease that you may have. The physician will then examine your legs. Once the initial exam is complete, your physician may decide that further testing is required, such as duplex ultrasound or doppler exams of the legs. These non-invasive procedures use sound waves to evaluate the function of the veins of the leg. These tests are very important in order to plan the most appropriate therapy.
Once all the necessary information is obtained your physician will discuss the treatment options with you. There should also be a discussion of the possible side effects and complications of sclerotherapy and or other treatments suggested. You should also discuss the cost of the recommended treatments. Very often the first treatment can be done on the same visit as the consultation. Figure 1a shows spider veins on a thigh before treatment. Figure 1b shows the same thigh after several treatments with clearing of the spider veins.
Side effects of sclerotherapy
You may experience certain side effects after sclerotherapy. Mild side effects may occur for one or two days after the procedure such as raised red bumps, itching, swelling, or bruising at the injection sites. Sometimes bruising can last for up to 10 days. These side effects are typically minor and short lived. Other sclerotherapy side effects include:
(1) Veins may become lumpy and hard. This may take several months to dissolve and fade. This is more typical of treatment of large veins. In most cases the treatment of spider veins does not cause these side effects.
(2) Brown lines or spots may appear at the vein site. In most cases, they disappear within three to six months.
(3) Neovascularization may occur, appearing as new tiny spider veins at the site of sclerotherapy treatment. These tiny veins can appear days or weeks after the procedure and usually fade within three to twelve months without further treatment. In some cases these small spider veins may persist.
(4) In rare cases the solution injected may irritate the skin, causing a skin ulceration (open sore).
These heal slowly and may leave a scar.
(5) Inflammation of the superficial veins (superficial phlebitis) may occur following treatment causing a localized hardness, redness, swelling, and tenderness. This slowly resolves on its own, and will be helped by anti-inflammatory agents such as Advil, Aleve, or other NSAID (non-steroidal anti-inflammatory drug) that can be prescribed by your physician.
(6) A blood clot may develop in the deeper veins of the leg causing a deep phlebitis (deep vein thrombosis). Patients typically develop a painful swollen leg. This is potentially serious, a clot may break off from the vein and travel to the lung causing a pulmonary embolism. These problems require immediate medical attention. Fortunately these complications are rare.
(7) Allergic reactions to the injected sclerosing agents may occur during the treatment, or within 24 hours after treatment. If you have a history of allergies, you have a greater chance of experiencing an allergic reaction to the agents. A minor allergic reaction will cause itching and swelling. More serious allergic reactions may rarely occur causing anaphylactic shock. This is serious and requires immediate medical attention. Fortunately this complication is also very rare.
Will the treated veins come back?
Treated correctly, the veins will not come back, as the body has absorbed them. New veins however, may appear with time, as the same causative hereditary factors still exist. These new veins are generally less pronounced and can be easily treated. In some patients maintenance treatments are required to keep new vessel growth to a minimum.