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
Indianapolis, Indiana