which takes its name from a Greek
word meaning "hardening,"
is a method of treating enlarged veins
by injecting an irritating chemical
called a sclerosing agent into the
vein. The chemical causes the vein
to become inflamed, which leads to
the formation of fibrous tissue and
closing of the lumen, or central channel
of the vein.
in the legs is performed for several reasons.
It is most often done to improve the appearance
of the legs, and is accomplished by closing
down spider veins—small veins in the
legs that have dilated under increased venous
blood pressure. A spider vein is one type
of telangiectasia, which is the medical
term for a reddish-colored lesion produced
by the permanent enlargement of the capillaries
and other small blood vessels. The word
telangiectasia comes from three Greek words
that mean "end," "blood vessel,"
and "stretch out." In a spider
vein, also called a "sunburst varicosity"
there is a central reddish area that is
visible to the eye because it lies close
to the surface of the skin; smaller veins
spread outward from it in the shape of a
spider's legs. Spider veins may also appear
in two other common patterns—they
may look like tiny tree branches or like
extra-fine separate lines. In addition to
the cosmetic purposes sclerotherapy serves,
it is also performed to treat the soreness,
aching, muscle fatigue, and leg cramps that
often accompany small- or middle-sized varicose
veins in the legs. It is not, however, used
by itself to treat large varicose veins.
is usually considered a cosmetic procedure,
it is usually not covered by health insurance.
People who are being treated for cramps
and discomfort in their legs, however, should
ask their insurance companies whether they
are covered for sclerotherapy. In 2001,
the average cost of the procedure was $227.
as a general treatment modality is also
performed to treat hemorrhoids (swollen
veins) in the esophagus.
American College of Phlebology (ACP), a
group of dermatologists, plastic surgeons,
gynecologists, and general surgeons with
special training in the treatment of venous
disorders, comments that more than 80 million
people in the United States suffer from
spider veins or varicose veins. The American
Society of Plastic Surgeons (ASPS) estimates
that 50% of women over 21 in the United
States have spider veins.Women
are more likely to develop spider veins
than men, but the incidence among both sexes
increases with age. The results of a recent
survey of middle-aged and elderly people
in San Diego, California, show that 80%
of the women and 50% of the men had spider
veins. Men are less likely to seek treatment
for spider veins for cosmetic reasons, however,
because the discoloration caused by spider
veins is often covered by leg hair. On the
other hand, men who are bothered by aching,
burning sensations or leg cramps, can benefit
to the ASPS, there were 616,879 sclerotherapy
procedures performed in the United States
in 2001; 97% were performed on women and
3% were done on men. Most people who are
treated with sclerotherapy are between the
ages of 30 and 60.
veins are most noticeable and common in
Caucasians. Hispanics are less likely than
Caucasians but more likely than either African
or Asian Americans to develop spider veins.
understand how sclerotherapy works, it is
helpful to begin with a brief description
of the venous system in the human body.
The venous part of the circulatory system
returns blood to the heart to be pumped
to the lungs for oxygenation. This is in
contrast to the arterial system, which carries
oxygenated blood away from the heart to
be distributed throughout the body. The
smallest parts of the venous system are
the capillaries, which feed into larger
superficial veins. All superficial veins
lie between the skin and a layer of fibrous
connective tissue called fascia, which covers
and supports the muscles and the internal
organs. The deeper veins of the body lie
within the muscle fascia. This distinction
helps to explain why superficial veins can
be treated by sclerotherapy without damage
to the larger veins.
contain one-way valves that push blood inward
and upward toward the heart when they are
functioning normally. The blood pressure
in the superficial veins is usually low,
but if it rises and remains at a higher
level over a period of time, the valves
in the veins begin to fail and the veins
dilate, or expand. Veins that are not functioning
properly are said to be "incompetent."
As the veins expand, they become more noticeable
because they lie closer to the surface of
the skin, forming the typical patterns seen
in spider veins.
people are at greater risk for developing
spider veins. These risk factors include:
Females in any age group are more likely
than males to develop spider veins.
Genetic factors. Some people have veins
with abnormally weak walls or valves.
They may develop spider veins even without
a rise in blood pressure in the superficial
Pregnancy. A woman's total blood volume
increases during pregnancy, which increases
the blood pressure in the venous system.
In addition, the hormonal changes of
pregnancy cause the walls and valves
in the veins to soften.
Using birth control pills.
Obesity. Excess body weight increases
pressure on the veins.
Occupational factors. People whose jobs
require standing or sitting for long
periods of time without the opportunity
to walk or move around are more likely
to develop spider veins than people
whose jobs allow more movement.
During sclerotherapy for the treatment of
varicose veins, the doctor injects a chemical
solution directly into the vein (A and B).
The needle travels up the vein, and as it
is pulled back, the chemical is released,
causing the vein to form fibrous tissue
that collapses the inside of it (C). (Illustration
by GGS Inc.).
In typical outpatient sclerotherapy treatment,
the patient changes into a pair of shorts
at the doctor's office and lies on an examination
table. After cleansing the skin surface
with an antiseptic, the doctor injects a
sclerosing agent into the veins. This agent
is eliminated when the skin is stretched
tightly over the area with the other hand.
The doctor first injects the larger veins
in each area of the leg, then the smaller
ones. In most cases, one injection is needed
for every inch of spider vein; a typical
treatment session will require five to 40
separate injections. No anesthetic is needed
for sclerotherapy, although the patient
may feel a mild stinging or burning sensation
at the injection site.
liquid sclerosing agents that are used most
often to treat spider veins are polidocanol
(aethoxysklerol), sodium tetradecyl sulfate,
and saline solution at 11.7% concentration.
Some practitioners prefer to use saline
because it does not cause allergic reactions.
The usual practice is to use the lowest
concentration of the chemical that is still
effective in closing the veins.
newer type of sclerosing agent is a foam
instead of a liquid chemical that is injected
into the veins. The foam has several advantages:
It makes better contact with the wall of
the vein than a liquid sclerosing agent;
it allows the use of smaller amounts of
chemical; and its movement in the vein can
be monitored on an ultrasound screen. Sclerosing
foam has been shown to have a high success
rate with a lower cost, and causes fewer
all the veins in a specific area of the
leg have been injected, the doctor covers
the area with a cotton ball or pad and compression
tape. The patient may be asked to wait in
the office for 20–30 minutes after
the first treatment session to ensure that
there is no hypersensitivity to the sclerosing
chemicals. Most sclerotherapy treatment
sessions are short, lasting from 15 to 45
minutes.It is not unusual for patients to
need a second treatment to completely eliminate
the spider veins; however, it is necessary
to wait four to six weeks between procedures.
The most important aspect of diagnosis prior
to undergoing sclerotherapy is distinguishing
between telangiectasias and large varicose
veins, and telangiectasias and spider nevi.
Because sclerotherapy is intended to treat
only small superficial veins, the doctor
must confirm that the patient does not have
a more serious venous disorder.
nevi, which are also called "spider
angiomas," are small, benign reddish
lesions that consist of a central arteriole,
which is a very small branch of an artery
with smaller vessels radiating from it.
Although the names are similar, spider nevi
occur in the part of the circulatory system
that carries blood (away) from the heart,
whereas spider veins occur in the venous
system that returns blood to the heart.
To distinguish between the two, the doctor
will press gently on the spot in the center
of the network. A spider nevus will blanch,
or lose its reddish color, when the central
arteriole is compressed. When the doctor
releases the pressure, the color will return.
Spider veins are not affected by compression
in this way. In addition, spider nevi occur
most frequently in children and pregnant
women, rather than in older adults. They
are treated by laser therapy or electrodesiccation,
rather than by sclerotherapy.
taking the patient's medical history, the
doctor examines the patient from the waist
down, both to note the location of spider
veins and to palpate (touch with gentle
pressure) them for signs of other venous
disorders. Ideally, the examiner will have
a small raised platform for the patient
to stand on during the examination. The
doctor will ask the patient to turn slowly
while standing, and will be looking for
scars or other signs of trauma, bulges in
the skin, areas of discolored skin, or other
indications of chronic venous insufficiency.
While palpating the legs, the doctor will
note areas of unusual warmth or soreness,
cysts, and edema (swelling of the soft tissues
due to fluid retention). Next, the doctor
will percuss certain parts of the legs where
the larger veins lie closer to the surface.
By gently tapping or thumping on the skin
over these areas, the doctor can feel fluid
waves in the veins and determine whether
further testing for venous insufficiency
is required. If the patient has problems
related to large varicose veins, these must
be treated before sclerotherapy can be performed
to eliminate spider veins.
conditions and disorders are considered
contraindications for sclerotherapy:
- Pregnancy and
lactation. Pregnant women are advised
to postpone sclerotherapy until at least
three months after the baby is born,
because some spider veins will fade
by themselves after delivery. Nursing
mothers should postpone sclerotherapy
until the baby is weaned because it
is not yet known whether the chemicals
used in sclerotherapy may affect the
- A history of
AIDS, hepatitis, syphilis, or other
diseases that are carried in the blood.
- Heart conditions.
- High blood
pressure, blood clotting disorders,
and other disorders of the circulatory
Patients are asked to discontinue aspirin
or aspirin-related products for a week before
sclerotherapy. Further, they are told not
to apply any moisturizers, creams, tanning
lotions, or sunblock to the legs on the
day of the procedure. Patients should bring
a pair of shorts to wear during the procedure,
as well as compression stockings and a pair
of slacks or a long skirt to cover the legs
afterwards. Most practitioners will take
photographs of the patient's legs before
sclerotherapy to evaluate the effectiveness
of treatment. In addition, some insurance
companies request pretreatment photographs
for documentation purposes.
following sclerotherapy includes wearing
medical compression stockings that apply
either 20–30 mmHg or 30–40 mmHg
of pressure for at least seven to 10 days
(preferably four to six weeks) after the
procedure. Wearing compression stockings
minimizes the risk of edema, discoloration,
and pain. Fashion support stockings are
a less acceptable alternative because they
do not apply enough pressure to the legs.The
surgical tape and cotton balls used during
the procedure should be left in place for
48 hours after the patient returns home.
are encouraged to walk, ride a bicycle,
or participate in other low-impact forms
of exercise (examples: yoga and tai chi)
to prevent the formation of blood clots
in the deep veins of the legs. They should,
however, avoid prolonged periods of standing
or sitting, and such high-impact activities
Cosmetically, the chief risk of sclerotherapy
is that new spider veins may develop after
the procedure. New spider veins are dilated
blood vessels that can form when some of
the venous blood forms new pathways back
to the larger veins; they are not the original
blood vessels that were sclerosed. Some
patients may develop telangiectatic matting,
which is a network of new spider veins that
surface around the treated area. Telangiectatic
matting usually clears up by itself within
three to 12 months after sclerotherapy,
but it can also be treated with further
risks of sclerotherapy include:
thrombosis. A potentially serious complication,
thrombosis refers to the formation of
blood clots in the veins.
Pain after the procedure lasting several
hours or days. This discomfort can be
eased by wearing medical compression
stockings and by walking briskly.
Allergic reactions to the sclerosing
solution or foam.
Loss of feeling resulting from damage
to the nerves in the treated area.
Edema (swelling) of the foot or ankle.
This problem is most likely to occur
when the foot or ankle is treated for
spider veins. The edema usually resolves
within a few days or weeks.
Brownish spots or discoloration in the
skin around the treated area. These
changes in skin color are caused by
deposits of hemosiderin, which is a
form of iron that is stored within tissue
cells. The spots usually fade after
Ulceration of the skin. This complication
may result from reactive spasms of the
blood vessels, the use of overly strong
sclerosing solutions, or poor technique
in administering sclerotherapy. It can
be treated by diluting the sclerosing
chemical with normal saline solution.
Hirsutism. Hirsutism is the abnormal
growth of hair on the area treated by
sclerotherapy. It usually develops several
months after treatment and goes away
on its own. It is also known as hypertrichosis.
Normal results of sclerotherapy include
improvement in the external appearance of
the legs and relief of aching or cramping
sensations associated with spider veins.
It is common for complete elimination of
spider veins to require three to four sclerotherapy
and mortality rates
Mortality associated with sclerotherapy
for spider veins is almost 0% when the procedure
is performed by a competent doctor. The
rates of other complications vary somewhat,
but have been reported as falling within
the following ranges:
discoloration: 10%–80% of patients,
with fewer than 1% of cases lasting
longer than a year.
matting: 5%–75% of patients.
- Deep venous
thrombosis: Fewer than 1%.
- Mild aching
or pain: 35%–55%.
- Skin ulceration:
who are experiencing some discomfort from
spider veins may be helped by any or several
of the following approaches:
Walking or other forms of exercise that
activate the muscles in the lower legs
can relieve aching and cramping because
these muscles keep the blood moving
through the leg veins. One exercise
that is often recommended is repeated
flexing of the ankle joint. By flexing
the ankles five to 10 times every few
minutes and walking around for one to
two minutes every half hour throughout
the day, the patient can prevent the
venous congestion that results from
sitting or standing in one position
for hours at a time.
Avoiding high-heeled shoes. Shoes with
high heels do not allow the ankle to
flex fully when the patient is walking.
This limitation of the range of motion
of the ankle joint makes it more difficult
for the leg muscles to contract and
force venous blood upwards toward the
Elevating the legs for 15–30 minutes
once or twice a day. This change of
position is frequently recommended for
reducing edema of the feet and ankles.
Wearing compression hosiery. Compression
benefits the leg veins by reducing inflammation
as well as improving venous outflow.
Most manufacturers of medical compression
stockings now offer some relatively
sheer hosiery that is both attractive
and that offers support.
Medications. Drugs that have been used
to treat the discomfort associated with
spider veins include nonsteroidal anti-inflammatory
drugs (NSAIDs) and preparations of vitamins
C and E. One prescription medication
that is sometimes given to treat circulatory
problems in the legs and feet is pentoxifylline,
which improves blood flow in the smaller
capillaries. Pentoxifylline is sold
under the brand name Trendar.
If appearance is the patient's primary concern,
spider veins on the legs can often be covered
with specially formulated cosmetics that
come in a wide variety of skin tones. Some
of these preparations are available in waterproof
formulations for use during swimming and
other athletic activities.
laser therapy, and pulsed light therapy
Electrodesiccation is a treatment modality
whereby the doctor seals off the small blood
vessels that cause spider veins by passing
a weak electric current through a fine needle
to the walls of the veins. Electrodesiccation
seems to be more effective in treating spider
veins in the face than in treating those
in the legs; it tends to leave pitted white
scars when used to treat spider veins in
the legs or feet.
electrodesiccation, works better in treating
facial spider veins. The sharply focused
beam of intense light emitted by the laser
heats the blood vessel, causing the blood
in it to coagulate and close the vein. Various
lasers have been used to treat spider veins,
including argon, KTP 532nm, and alexandrite
lasers. The choice of light wavelength and
pulse duration are based on the size of
the vein to be treated. Argon lasers, however,
have been found to increase the patient's
risk of developing hemosiderin discoloration
when used on the legs. The KTP 532nm laser
gives better results in treating leg spider
veins, but is still not as effective as
pulsed light (IPL) systems
differ from lasers because the light emitted
is noncoherent and not monochromatic. The
IPL systems enable doctors to use a wider
range of light wavelengths and pulse frequencies
when treating spider veins and such other
skin problems, as pigmented birthmarks.
This flexibility, however, requires considerable
skill and experience on the part of the
doctor to remove spider veins without damaging
the surrounding skin.
and alternative (CAM) treatments
According to Dr. Kenneth Pelletier, the
former director of the program in complementary
and alternative treatments at Stanford University
School of Medicine, California, horse chestnut
extract is as safe and effective as compression
stockings when used as a conservative treatment
for spider veins. Horse chestnut (Aesculus
hippocastanum) has been used in Europe for
some years to treat circulatory problems
in the legs; most recent research has been
conducted in Great Britain and Germany.
The usual dosage is 75 mg twice a day, at
meals. The most common side effect of oral
preparations of horse chestnut is occasional
indigestion in some patients.
to "Varicose Veins Treatment"