I was asked just recently to talk about the “state of the art” in treating spider veins. As I was preparing that presentation, I happened to notice a big review article on that very topic in the current issue of Phlebology, a major vein practice related journal. Being already in the groove, I thought that would be the perfect topic for my second post here.
You would think in 2018 that modern medical science would have spider veins all figured out. A common complaint we hear from new patients is that they have had injections performed on their spider veins in the past, experienced some initial clearing, but then the problem returned within several months and seems to be even worse now. Spider veins can be stubborn and although the causes and risk factors are still largely unknown, there are some basic principles that we follow at Precision Vein Therapeutics to maximize your chances of a fantastic, long lasting result.
“Telangiectasias” is the medical term for spider veins but it’s way too hard for me to type. From now on out, I will refer to them as spiders. Anyone that knows me understands how little I care for spiders. I’m the guy that is perfectly willing to jump out of a moving vehicle if I find a spider on me. I want them off of me. I want them off of you. Know that my heart is in this.
Patients have lots of choices when it comes to the treatment of spiders. As a phlebologist, my approach is geared towards not just treating what’s on the surface but understanding what the underlying cause is and treating that as well. Insurance companies consider spider veins, even those that cause symptoms, as a cosmetic concern and not a medical necessity, and therefore, not covered. Knowing that patients are paying out of pocket, with their hard-earned money, motivates me to make darn sure that I am not just treating a problem that will come right back in short order because the real, underlying issue has not been addressed.
Although spiders can cause symptoms, prickly type pain and a burning sensation are common complaints, most patients seek treatment due to aesthetic concerns. Often, the problem has existed for many years and patients have been simply too busy with LIFE to have anything done about it. At a certain point, either folks just get fed up with only being able to wear long pants, or sometimes it’s other issues that develop, such as varicose veins. Whatever reason brings patients to treatment, the first questions usually asked are, “What causes this? Can we just laser these off? and What can I do to prevent these in the future?”. The big three. Here we go.
What causes this?
We don’t for sure. It’s “still a mystery”. I’m not kidding. That’s an exact quote and the reference to the review I mentioned earlier is at the bottom of this. Make no mistake though, we’ve got theories. There is good evidence for all of them too. The simple explanation is that not all spiders are the same. You see these big hairy tarantulas that have names and birth certificates and ride around on the guy’s shoulder on YouTube. I absolutely hate those angry little jumper spiders that look like crabs with their pinchers up and dare you to brush them off the couch. There is nothing more terrifying to me than walking right into the web that those freakishly large wolf spiders around my house build right across the path to the outside faucet. You knock them down. They come right back the next day. Annoying.
Different types of spiders can occur on your legs at the same time too. We know that somewhere between 30 and 50% of spider veins are associated with reflux, or retrograde blood flow in the underlying saphenous veins. Simply injecting the spiders with sclerosants (see my website for more on this), will set you up for failure because without treating the underlying source of venous pressure, recurrence is almost certain. This is the exact reason that we make great effort to explain to patients why we perform a venous ultrasound examination on every leg affected by spiders. You will hear us talk a lot about results and reputation. Everything we do is focused on that. We don’t deny the fact that vein disease tends to be progressive and that recurrence, even with the most meticulous techniques is possible and we mention that with all patients and in all printed materials. What we are after is the clearest, longest lasting result we can attain for the investment our patients are making.
In those cases where spider veins do exist in areas of underlying saphenous vein reflux, effective treatment with endovenous laser ablation of the saphenous vein (see the treatment section of my website), greatly enhances the success of sclerotherapy of the spiders.
For the types of spiders not caused by underlying saphenous vein reflux, two possible explanations include the failure of valves within the tiny vessels called perforator veins which connect the veins on the surface to the deeper veins of the legs, and also actual direct connections to tiny vessels from the arterial side of the circulation called arterioles. This is the reason that we discuss the small possibility of ulceration, or the formation of a sore at the site of sclerotherapy injection. This is also precisely the reason that we use low concentrations of sclerosing agents and special injection techniques when we perform sclerotherapy of spider veins. This risk of ulceration is very small (<1%) with our considerations.
Okay that’s scary, can we just laser these things off?
There are areas of the body such as the face where the success of laser treatment of spider veins is widely known. Lasers employ thermal destruction of vessels and most have very specific settings for a particular depth of tissue. In the legs, the vessels that need to be treated exist at deeper and more varied locations, with thicker walls requiring higher laser energies and specific measures to decrease the risk of burning the epidermis. As stated earlier, most spiders are associated with increased reverse pressure from larger deeper veins. Most lasers will not treat these associated high-pressure veins. Injection directly into a target vessel with spread of a sclerosing agent (sclerotherapy) into connected spiders is a much more efficient method to treat larger areas more quickly than laser. As this latest review states that I keep referencing as well as most books on the subject, sclerotherapy remains the treatment of choice for spiders because it has the advantage of eliminating the larger feeding veins as well.
Okay, sign me up but what can I do in the future to prevent these ugly things?
Some risk factors such as heredity, hormones, pregnancy (see my last blog entry), and age we can’t do much about. Those things are why we have to live with a certain risk of recurrence of vein problems no matter what we do and how much we hate to admit that possibility. With good, thoughtful sclerotherapy, most patients will need a touch up to maintain their results about once a year.
The other risk factors, we jump all over.
Sun exposure.
There is a direct correlation here. Sunlight degrades collagen and elastic fibers and that is what you don’t want. If you already have a familial tendency to have spider veins or think you might want to have a bunch of babies (which I highly recommend), don’t forget the sunscreen. Lather up with a reasonable number SPF (at least 30) when you are outside starting early in life and during the day and reapply at lunchtime. Your 55 and 65 and 75 and 85-year-old self will thank you.
Obesity.
Yes, there’s a study. We know that obese and overweight patients have a higher prevalence of the underlying venous pressure problems that cause spiders. Not all obese patients have spider veins though so this again comes back to other risk factors. With a strong family history of severe venous problems, the appearance of spider veins can be a sign of deeper issues which may only worsen in the presence of unmanaged weight problems.
Trauma.
Patients often relate an episode of localized trauma to the appearance of an area of spider veins. Damage to blood vessels in an area of trauma releases factors that we know stimulate blood vessel growth. Can’t really avoid trauma. You never know when or where it’s going to happen. It’s like the lightning bolt that took out the clock tower on Back to the Future.
Other things we discuss with patients regarding spiders:
It always takes more than one treatment session. With sclerotherapy, as I stated earlier, patients pay for this out of pocket per session. We know that good sclerotherapy will take out 60-80% of the total burden. Even patients with a small amount of spider veins usually require at least 2 sessions. Most require 3 or 4 sessions for clearance. This goes back to the different types of spiders. Some spider veins are more resistant than others. Most clinics that perform sclerotherapy charge between $200-$300+ per leg.
Expectations are important. Long standing spider veins carry a risk of staining of the skin in many instances due to the presence of hemosiderin, the breakdown product of hemoglobin that has accumulated in the skin over the spider vein as a consequence of long term extravasation of red blood cells under the venous pressure that exists in the area. The spider vein that is treated will be resorbed by the body but the stain above it may remain for some time. This is another great reason for patients to have early treatment of spiders.
Recurrence. Said it before and it bears saying again. We tell patients that have had previous sclerotherapy and have experienced recurrence they may have an untreated underlying source. We perform a complete venous ultrasound on every patient and we are completely upfront about the fact that most insurance carriers will refuse payment for ultrasound examinations in cases of pure cosmetic spiders when no underlying reflux is found. The ultrasound examination fee would be an out of pocket expense but we absolutely believe it is well worth the expense in avoiding that situation of needless repeated sessions of expensive sclerotherapy that are doomed to failure. To fully milk my spider analogies for this blog entry, it’s like killing the house spider but leaving behind that nice big egg sac.
On this website, I describe the treatments we have available at Precision Vein Therapeutics and in the evaluation and effective treatment of spiders, microphlebectomy is an extremely important weapon in our arsenal. In certain clinical presentations, particularly involving the outside area of the thigh, actual removal of the superficial vein feeding the spider vein cluster is curative. Microphlebectomy is performed under local anesthesia, however we do offer mild sedation in one of our treatment rooms on site. We use tiny incisions at short intervals along the vein and remove it using micro surgical hooks. The incisions typically heal without a scar and do not require suturing.
To wrap this up, as in most areas of medicine, there’s still a lot about spider veins that we’ve yet to figure out completely. The good news is that there are incredibly effective treatment options available and well-known techniques to maximize results. Be confident and get fed up with the spiders in your life and don’t wait another minute to do something about them. Call us at Precision Vein Therapeutics, 205-710-3800 for an appointment and let us help you rediscover healthy legs that look great and feel even better!
Reference: Pathophysiology of telangiectasias of the lower legs and its therapeutic implication: A systematic review. P Kern. Phlebology 2018, Vol. 33(4) 225-233.