In That Vein
Sclerotherapy pearls for today’s practice.
More than 80 million people have leg vein disease, ranging from small broken blood vessels to larger, sometimes painful bulging varicose veins.
Endovenous laser ablation (EVLA) is preferred for excising bulging varicose veins. Sclerotherapy is the gold standard for telangiectasias, venulectasias, and blue reticular veins in the legs, as laser light therapy often aggravates such small venous disease.
We have choices as to what agents to use for sclerotherapy, namely detergents such as polidocanol (Asclera) and sodium tetradecyl sulfate (STS, Sotradecol), both of which can be made into a foam. Osmotic agents, such as glycerin, are options, especially for the smallest of veins. While hypertonic saline is far inferior to detergents and osmotics, it can be used if the patient is allergic to other sclerosants.
Foam sclerosants confer some important benefits for patients and physicians. First, they increase the efficacy of the sclerosant in larger vessels, as bubbles displace blood, increasing the contact time between the sclerosant and the vein’s endothelium. Moreover, we need a lower concentration and volume of foam compared to liquid sclerosants. (Of note, foam sclerosant agents should be used with caution in patients with patent foramen ovale.)
I always use alcohol-soaked cotton balls to cleanse and prep the skin before initiating sclerotherapy. I treat the veins in an algorithmic fashion from the proximal to the distal veins, using a 30-gauge needle, which can cannulate even small telangiectasias. I may bend the needle for a better tangential approach on an as-needed basis.
In terms of technique, I have learned that if you’re not cannulating vessels, you are in too deep. I continue treatment as long as vessel changes are apparent but will stop if severe pain develops during the procedure.
After treatment, patients remain in the supine position for several minutes. I apply a potent corticosteroid solution and prescribe 30-40mm/Hg graduated thigh-high compression stockings to be worn around the clock for one week.
Expectation management plays a role in patients’ ultimate satisfaction with the sclerotherapy procedure. Succesful treatment typically involves a series of three to six sessions, and patients need to know this up-front. It is not necessarily a “one-and-done” procedure. A single session may improve the appearance of treated veins by approximately 40 percent. I make sure patients consider the time of year before they book the procedure, as recovery involves wearing compression hose, which can be unbearable during a summer heat wave.
The Right Pairing
Sclerotherapy—especially when performed with a foaming agent—still has a very important place in our armamentarium for treating leg vein disease. When paired with the right patient, sclerotherapy produces impressive aesthetic results and also improves patient self-esteem.
Disclosure: Melanie Palm, MD is a speaker, physician trainer, clinical investigator, and advisory board member for Galderma, Allegan, and, Merz; Advisory board member; speaker, and physician trainer for Lumenis; speaker and consultant for Lutronic, and speaker and clinical investigator for BTL.
Melanie D. Palm, MD, MBA, is a board-certified dermatologist and fellowship-trained cosmetic surgeon. She is Director of Art of Skin MD in San Diego and Assistant Clinical Professor at the University of California, San Diego. This article is based on a talk given at Cosmetic Surgery Forum 2016 in Las Vegas. The 2017 meeting will be November 29-December 2: CosmeticSurgeryForum.com.