Nurse prescriber Claire Judge explains the treatment of thread veins
Microsclerotherapy is a cosmetic procedure used for the treatment of unsightly thread or spider veins on the leg. These are abnormally dilated superficial veins (CEAP class 1)1 that can cover wide areas of the legs. Generally, they are asymptomatic, but they can cause itching, swelling and discomfort and can affect more than 40% of the female population over the age of 50.2 Men are thought to be less susceptible to thread veins due to lower levels of the hormone progesterone, but in my experience, they can still be treated successfully. Patients of all skin tones can get thread veins, but they appear much more obviously with paler skin and the majority of patients presenting with thread/spider veins have a strong family history of the condition, and pregnancy and hormonal changes will aggravate their propensity.3 Many patients who are concerned about these veins will investigate potential treatments on the internet, and come to an initial consultation expecting overnight perfection following one treatment, after seeing a video of someone’s veins instantly disappearing. This article aims to clarify what the practitioner should be communicating to the patient about the treatment process, as patients who have their expectations managed at the outset will be far happier with the outcome.3
Patient selection is paramount and suitability must be established, predominantly by ascertaining whether they will be able to successfully keep up with the aftercare. Absolute contraindications include known allergies to the sclerosant, acute deep vein thrombosis or a pulmonary embolism, local infection in the area of sclerotherapy or a severe generalised infection, pregnancy and breastfeeding and long-lasting immobility.4
Taking photographs pre-operatively shows patients the extent of change since treatment started, enabling them to see the progress made, rather than visualising an idealised image of how their legs could look.4
Sclerotherapy is a skilful technique which involves cannulating fine veins and injecting a sclerosing agent. The agent I use is Aethoxysklerol sodium tetradecyl sulfate, which I have been using for more than 25 years and have found it has less risks of side effects than other sclerosants, in particular staining and ulceration. The sclerosant liquid solution damages the lining of the vein walls causing swelling, hence the injected vein will swell and shut, so the blood is redirected to unaffected veins. This can cause the misleading results seen on social media that the treatment has immediate and final results. The affected veins form a fibrous cord that is absorbed over time.5 I use a 30 gauge needle with a 5ml syringe. A 10-30 degree bend is placed in the needle with the bevel up (Figure 1). Approximately 0.2ml of Aethoxysklerol 5mg/ml is injected into the vein. Whilst injecting, the skin should be stretched taut to ease cannulation and patient comfort. Pressure is applied to the skin, restricting the area of drug dispersal. Efficacy of the drug has been shown to diminish with increasing distance from the entry site so practitioners should only blanch a 2cm square area, and low pressure will also help reduce intra luminal trauma.2
In my experience, legs often look worse before they improve and there are side effects that patients should be made aware of at the outset, including staining, lumpiness and tenderness over some areas, ulceration and failure of the treatment.6 Staining is a common side effect, occurring in 10-30% of patients in the short term and it usually settles within the year for around 80% of patients.7 It occurs due to deposits of melanin and haemosiderin pigment as a result of post-inflammatory processes and haemosiderin deposition. If the drug is injected under high pressure into a superficial larger fragile vein, this may cause a higher incidence of staining due to rupture of these vessels. This causes the release of haemoglobin into the dermis which is degraded into haemosiderin. Thus, using larger volume syringes may help reduce this risk.7 Some patients will have innate tendency toward cutaneous pigmentation (total body iron stores and/or altered iron transport and storage mechanisms).7 There is no consensus as to whether there is a higher risk of staining with patients who have dark skin and dark hair, but this side effect has also been reported in these patients.6,8 Other rarer side effects can include allergic reactions and migraines.4 Another potential concern is extravasation of the drug, which can be caused by incorrect siting of the needle.4 If this occurs, the injection should immediately stop, and the resulting bleb should be massaged until the drug disperses.9 As the drug enters the vein often there is no discomfort; however, rarely, the patient my feel a slight stinging. Once completed the veins may feel slightly itchy (this is more common distally) and urticaria may occur as the earliest manifestation of perivascular inflammation.9 During this process I would spend time talking to the patient to both reassure and distract them. This is also an effective way to assess the patient’s tolerance and welfare throughout the procedure.
After treatment of larger flares or more substantial reticular veins, cotton wool balls provide immediate pressure to the area, held in place with micropore. On completion of treatment, I will tell the patient to remain lying flat, and will measure them for class 2 graduated compression stockings (30mmhg) from foot to thigh.
Compressing the veins immediately is thought to be beneficial for reducing the risk of undesirable side effects such as post sclerosis pigmentation, temporary ankle oedema and telangiectatic matting.10 It creates direct apposition of the vein walls producing effective sclerosis by limiting thrombus formation. This in turn may minimise telangiectatic matting.10 Compression is also useful as it can augment the body’s natural muscle pump.11 Although the need for compression for varicose veins is universally recommended, there is ongoing debate regarding the need to compress when treating thread veins.8 However, a significant number of thread veins are fed by larger reticular or varicose veins, thus, by reducing the blood flow through compression it is likely that blood flow to the smaller vessels will be more effectively sclerosed with a subsequent decrease in recanalisation.8 For the 52-year-old patient seen in Figure 2, I recommended she wear her stockings for 72 hours continuously, and then for a further three days during the daytime. This was due to the presence of large webs and flares and some reticular veins that I felt would benefit from extra compression. Moreover, the patient was a nurse and on her feet a lot, therefore there would be increased pressure on the veins.
Microsclerotherapy is an effective treatment for thread veins; however, it is not perfect. Although quick to undertake, the treatment may take many months for the full outcome to be seen. The veins that have been treated will never return as the vein has collapsed, but new thread veins may appear. The images in this article are very typical of patients who are awaiting the results of their sclerotherapy treatment, and it is vital to manage patient expectations in terms of the length of the process. On browsing the internet, there are very few honest images to be found when researching how legs look in-between the before and after images. I think it is necessary for patients to fully understand that the treatment is not perfect and side effects are relatively common, albeit short term.
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