Spider veins of the legs are a common concern for many women. While their main concern is usually that of a cosmetic distraction, some women will have discomfort with them as well. They often appear in patches and may have deeper blue veins in the vicinity of the spider patch. This indicates, like the leafs on a tree, that spider veins are not isolated entities and are the result of valve incompetence of the larger venous system onto which they are conbected. This suggests that the treatment of spider veins in many cases will prevent further progression of the problem.

Despite the widespread availability and marketing of laser treatments, sclerotherapy is the gold standard in the treatment of spider veins. In the United States, the use of hypertonic saline and sodium tetradecyl sulphate (Sotradecol) are the two injectable agents available for use. While each has its proponents, there is no clear evidence that one is more effective than the other in experienced hands. Outside the United States, however, polidocanol (POL) is more commonly used.

Recently, POL has become approved for spider vein sclerotherapy in the United States and is now widely available. POL has had the reputation for years that it more effective than hypertonic saline or Sotradecol and has fewer potential skin and soft tissue complications should some of the solution get outside of the vessels. Is POL a better option for sclerotherapy and, if so, is it actually more safe?

In a 2010 issue of the journal Phlebology, a double-blind randomized comparative clinical trial of polidocanol, sodium tetradecyl sulphate and isotonic saline was published. In 316 patients, 160 spider veins and 156 larger reticular veins were treated with one of the tested injections. Digital images were taken prior to injection and at 12 and 26 weeks after the last injection. The study showed that more patients were satisfied with POL at 12 and 26 weeks (84%, 88%) compared to Sotradecol (64%, 63%) and isotonic saline. (14%, 11%) Injection site reactions (irritation, discoloration, necrosis) were significantly more frequent in patients treated with Sotradecol as compared with POL.

Requests for spider vein treatment are common in a plastic surgery practice. However, most plastic surgeons do not treat them for a variety of reasons including the lack of glamor in so doing and the tedious nature of providing the service. In my Indianapolis plastic surgery practice I do perform sclerotherapy and, under 2.5X loupe magnification, it is fairly easy to cannulate small vessels for the injections. Even though I have a laser that can treat spider veins, sclerotherapy in my hands is more effective, less painful and more economical for patients. POL is a welcome new agent for sclerotherapy, particularly if it has a higher safety profile.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

One of the most common cosmetic leg concerns is that of spider veins. The use of the term ‘spider veins’ is a bit contradictory as the vessel size one refers to with this term is the size of spider legs. But a true vein, in vessel terms, would be much larger. Medically speaking, spider veins are known as telangectasias. That refers to a vessel size that is somewhere between minute end capillaries and small reticular veins, usually 1 to 3 mms in diameter.

The treatment of spider veins can be done with either sclerotherapy or laser coagulation. Both can work and there are some specific advantages and disadvantages to either approach.

Sclerotherapy is the injection of a chemical solution into the spider vein. It is simple to do but requires skill to introduce the needle into the small vessel and not get the solution into the surrounding tissues. The solution irritates the vessel and causes it to clot off in the next several weeks. Once there is no blood flow into the spider vein, it is no longer visible. The spider vein will look red and raised over the week following the injections. The injected area is wrapped until the next day after the injections. Compressing the vein for a short period of time after helps the injected solution stay in the vessel and squeezes the sides of the vessel together. The success of sclerotherapy is often touted as being between 90% and 100%. In my Indianapolis plastic surgery experience, I tell patients to expect about 70% improvement or elimination of visible spider veins. Most patients will need a second or touch-up session for optimal clearing.

There are different sclerotherapy solutions and concentrations for use. These include concentrated or hypertonic saline and sodium sotradecol. A newer sclerotherapy solution has just been released by the FDA. Asclera, known generically as pilodocanal, is actually used around the world and is the preferred solution outside of the United States. It is reported to be more effective and comfortable to inject than what we historically have used here in the states. It is likely to replace these older agents in the near future as its use becomes more familiar.

The use of laser for the treatment of spider veins has become more popular than sclerotherapy, particularly for those that own a laser that has that capability. The laser is easier to hit the spider vein as it is a ‘point and shoot’ method rather than actually cannulating the vessel. Adjusting the settings on the laser is key as the power and depth of penetration of the laser light will determine both effectiveness and the avoidance of skin burns. The laser settings are a bit of an art form as the size and exact location of the spider veins in the skin or subcutaneous levels differs in every patient and level of the leg. I find that the laser is more more expensive and painful but not necessarily more effective over sclerotherapy.

My historic approach to spider veins of the legs is that ‘if you can stick it successfully with a needle, sclerotherapy is better than the laser.’ It is less expensive, less painful, and more consistently effective. To capture the benefits of both spider vein treatments, I will often combine the two in a technique known as Laser-Assisted Sclerotherapy. (LAS) Initially the spider vein is injected and then the laser is used to treat over the top of it. Since I use a Sciton laser, the settings are typically 70 joules and 50 milliseconds for a 6 to 8mm spot size. While these settings would be ineffective if done alone, they are adequate when combined with sclerotherapy. In my experience, this raises the effectiveness of the treatment closer to 90% which is better than sclerotherapy or laser alone.  

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana