1. Consultation is first done before any treatment.  Most insurances cover consultation when there are extensive abnormal veins on the leg with symptoms of leg pain.  If the consultation is entirely for cosmetic appearance without the presence of leg pain the charge is $75 which is later applied to the cost of cosmetic treatment.  If at the time of consultation more extensive problems are found on ultrasound which require remedy and treatment with ultrasound mapping, endovenous laser or ultrasound guided foam sclerotherapy, an approval in writing is first obtained by our office from the insurance company showing treatment is covered by insurance and considered medically necessary.
2. If the spider veins are entirely cosmetic the patient is scheduled for cosmetic sclerotherapy.  The protocol of treatment of entirely cosmetic spider veins consists of taking photographs of the leg, measuring for compression stockings and beginning therapy.  Treatment consists of 30 minute sessions of sclerotherapy by the physician.  In the average patient the worst leg is treated on the first visit.  The next leg is treated one to two weeks later in order to allow the doctor to assess whether any alteration in the concentration of solution used is indicated.  After the first session in each leg there is usually about a 50% clearing in the appearance of spider veins even though all the veins were treated during the session.  This is the “first coat”.  6-8 weeks are allowed before the third and fourth sessions.  After the final session most patients will have had a 75-85% clearing in the appearance of the spider veins which is a significant improvement.  After each session of sclerotherapy the patient is asked to walk while still in the office.  Compression stockings are then worn during the day for the next three weeks which is the optimum time found by controlled studies to aid in the clearing of spider veins.

Another common reason found for unsatisfactory results from sclerotherapy is doing too little treatment or doing a single treatment.  A “little bit” of sclerotherapy is analogous to shooting a tiger with a 22 calibre rifle.  You are doing the right thing but don’t have nearly enough firepower.  Just as using too little sclerosant is ineffective so also is doing a single treatment  Treating spider veins is like painting a room a new color.  A first coat of paint changes the color of the room but once it dries the old color still shows through in spots.  A second coat is what makes all the difference in appearance.  Successive treatment sessions of sclerotherapy is always the standard of successful treatment.

The effect of sclerotherapy is that the leg both looks and feels better.  Common temporary adverse side effects include some hyperpigmentation developing over large clusters of treated spider veins or larger varicose veins.  This occurs because the sclerotherapy causes the vein to shut down with some blood within the vein.  As the blood breaks down along with the vein iron from the hemoglobin can cause a slight brown area to develop in the skin, the “ghost” of the treated vein.  These areas of hyperpigmentation are temporary in the majority of patients but up to 4% of patients can have some small residual areas of hyperpigmentation lasting even 24 months after treatment.  This hyperpigmentation is more common in patients with skin that is dark or that tans very readily.  For that reason patients are asked to avoid intentionally tanning immediately after sclerotherapy.

Definitive treatment consists of either injection therapy (sclerotherapy) or lasers.  Lasers have been promoted by many manufacturers in the treatment of spider veins and many physicians, listening to them, have purchased these expensive machines and marketed them to their patients.  Lasers have only had modest success in the treatment of spider veins in the legs, however, because the complex relationship of one cluster of spider veins to another on the leg causes untreated veins to flow back into areas treated by topical lasers andreopen.  Consequently, many more treatments are necessary to gain a very modest amount of improvement.  Also, patients are frequently surprised as to how painful the lasers.  The lack of predictable or significant success has prompted the American College of Phlebology to recommend that lasers should be reserved for those patients with very small veins inaccessible to injection therapy or who are markedly needle phobic.  Facial spider veins are preferentially treated with laser though they may be treated with sclerotherapy as well.

Sclerotherapy (injection therapy) remains the “gold standard” in the treatment of spider vein disease of the legs where most spider veins occur.  Solutions injected inside the veins with very fine (30 gauge) needles cause the veins to scar shut and so the veins gradually wither away.

Part 2 of Treatment of spider veins will be here tomorrow!

Spider veins can appear anywhere on the body including the face, chest, back and arms but are most common on the legs.

Lesser risk factors include taking estrogen in the form of supplements or hormonal birth control. As many women have feared, crossing the legs has indeed been shown to increase the risk of spider veins developing at the knee. Also, spider veins are commonly found at sites of prior trauma (“a baseball hit my leg when I was young”) in patients who already had a genetic predisposition to the condition.

Most spider veins develop from this genetic trait and are on the legs though other common causes include sun damage and the effect of “vasodilators” such as alcohol causing the bright red nose that often was associated with drinking (but was more commonly the result of acne rosacea). Cirrhotic liver disease can impair venous return through the liver and cause both spider veins and varicose veins as well.

The backward flow has two effects. The first and most obvious effect is the backward flow engorges the vein as the blood is not able to empty normally. When this backward flow engorges very tiny fine veins in the skin the result is spider veins. These fine veins were present since we were but only became visible once backward flow engorged the vein.

When this backward flow affects larger and deeper veins the result is large lumpy varicose veins. Both spider veins and varicose veins originate from the same cause-a genetic trait affecting one-way valves in the veins so that they now flow backwards with gravity and engorge the vein. Spider and varicose veins differ only in appearance.

In addition to causing engorgement and the appearance of spider veins, the backward flow has a second effect which is of causing symptoms of pain. The backward flow of the blood in the veins means the blood in these veins is relatively “stagnant” compared to normal veins where the blood continuously moves forward to the heart. The “stagnant” blood inside a vein engorges it, thus raising the venous pressure and an inflammatory response occurs within the vein. The inflammatory vein serves as an irritant to nearby muscles and nerves and causes a variety of symptoms including itching, heaviness, burning, fatigue, aching, swelling and restlessness among others.

Next we will talk about the three main risk factors for developing spider veins…

Next we will talk about what causes their appearance and pain…