Podiatric Vein Care
The Cosmetic Approach: Veins on the Surface

Sclerotherapy and laser vein treatments are performed for the improvement of the appearance of telangiectasias - otherwise known as spider veins. When a patient presents with visible veins, the first key factor to successful treatment is to rule out any underlying venous insufficiency. Reticular veins and spider clusters that organize around the medial aspect of the knee or the medial and lateral malleolus region are red flags for underlying insufficiency. Once you have confirmed that there is no underlying insufficiency, treatment can be directed towards the surface of the skin. The two standard transcutaneous methods for treatment are injection and laser therapy. 

If there is underlying venous insufficiency, the key to success on either treatment modality is to identify the feeding reticular vein and treat that prior to treating any clusters of spider veins. The analogy I like to use is a tree. The reticular veins are the tree trunk and the spider veins are the leaves. If you would like to permanently destroy the branches and the leaves, you must dry up and kill the tree trunk first. By performing this in the appropriate stepwise approach, the general outcome of erased spider veins is improved and patient satisfaction is high. Without addressing the reticular vein, there is a high rate of recurrence, as old veins can return and new veins can form. 

The most effective laser for transcutaneous spider veins is a YAG laser. Through selective photothermolysis, hemoglobin is targeted. Heat energy is delivered to the vessel which damages the vessel wall and the body will gradually break it down. 

Sclerotherapy, which studies confirm is the gold standard of cosmetic vein treatment, is performed with injections into the veins. When treating reticular veins, it is recommended to aspirate blood into the hub of the needle prior to injection. This minimizes extravasation which causes negative side effects with a potent sclerosant. When treating spider veins, the point-and-shoot technique is acceptable, as the solution treating these smaller veins is weaker. Common agents include glycerol and saline and brand name agents such as Asclera® and Sotradecol® are FDA-approved for injection therapy. Although some doctors can get these agents compounded by a pharmacy, this practice is not recommended. Compounded agents tend to have more preservatives and the drug quality is questionable. This can lead to serious adverse effects that will upset the patient as they are seeking a cosmetic improvement, not scarring. Asclera® and Sotradecol® are a detergent like sclerosant and foam can also be made with these solutions. Foam is typically reserved for reticular veins or larger varicose veins, as foam increases the potential strength of the sclerosing agent and covers a larger surface volume. Foam is made by mixing the sclerosant with a gas, such as carbon dioxide.  

Most patients will require on average between three and five sessions of injection or laser therapy to obtain approximately 80 to 90% improvement. Patient expectation must be kept realistic and optimal improvement outcomes are noted three months after your final session. This is often discouraging for patients as they expect the cosmetic improvements immediately. It is also imperative that you have your patient understand that maintenance is often required.