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Heidi A. Waldorf, MD, On Small-Vessel Sclerotherapy
Despite the popularity of lasers in treating spider veins, one should not overlook the art of sclerotherapy.
Heidi A. Waldorf, MD, On Small-Vessel Sclerotherapy

With the recent FDA approval of the drug Asclera (polidocanol), sclerotherapythe traditional method of treating spider veins (or telangiectasias)may become more popular again. Though the procedure has been around for some 80 years and is still considered the best course of treatment by many medical professionals, it's been waning in popularity and appears to be becoming a lost art.

During this in-office procedure, veins are injected with a solution using small needles, which causes them to collapse and fade from view.

Typically, the procedure improves not only the cosmetic appearance but the associated symptoms. Even though more than 375,000 sclerotherapy procedures were performed in the United States in 2008, according to the American Society of Plastic Surgeons (ASPS), the number of sclerotherapy treatments has dropped nearly 60% since 2000.

Asclera is said to cause less discomfort, ulceration, and discoloration than traditional hypertonic saline and may even be a better option to the now more popular lasers.

The decline is because of new treatment options that use laser-based devices, says Heidi A. Waldorf, MD, a board-certified dermatologist in private practice in Nanuet, NY, and the director of laser and cosmetic dermatology and associate clinical professor at Mt Sinai Medical Center in New York City. During laser treatment, intense light eliminates the veins permanently. After a laser-based treatment, bruising usually occurs in the area treated and lasts for a few weeks. The cost of laser treatment for spider veins is usually higher compared with sclerotherapy.

As Waldorf explains, laser is newer, takes less time to do than sclerotherapy, and can be relegated to ancillary staff more readily. Waldorf uses both treatments, and PSP spoke with her recently about the different treatment approaches.

PSP: What is the appropriate use of sclerotherapy?

Heidi A. Waldorf, MD: Sclerotherapy is used solely for blood vessels. Although some people use sclerotherapy for the face for certain large blood vessels and hands, it is certainly not the place for a novice to start. And quite frankly, I don't find that those are areas that I treat. I think that there are other [treat- ments] that are better for those areas. I limit my sclerotherapy practice to smaller blood vessels of the leg. Most of the vessels that I treat are anywhere from matte telangiectasias, which are quite fineless than .1 mmup to about 3 mm.

Dr. Waldorf is shown doing a scleropathy procedure wearing a magnification lens with polarized light.

PSP: Are these visible veins dangerous to a patient?

Waldorf: Spider vesselsthese fine vessels that we're talking aboutare really a cosmetic concern, and they are not dangerous to the patient. If a patient, clinically, has large varicosities or other indications of deep vessel disease, a Doppler evaluation of blood flow and competency of the valves is necessary. Treatment of the small vessels won't be successful unless the source of incompetence is treated.

The larger vessels can also have medical implicationsthey predispose patients to chronic swelling, stasis dermatitis, and ulcer formation. These vessels are treated with endovenous radiofrequency or laser or ambulatory phlebectomy. Fine telangiectasia is treated with either sclerotherapy or laser.

The consensus is that if you can get a needle in, sclerotherapy is the most consistently effective. Vascular-specific lasers provide an alternative for needle-phobic patients or those who have had adverse effects from past sclerotherapy.

PSP: Who gets spider veins and varicose veins, what causes them, and can they be avoided?

Waldorf: The major risk factors of getting these vessels include being a woman, hereditary factors, pregnancy, a job requiring long hours standing, and anything else that's going to put extra stress or pressure on returning blood flow. For example, I see a lot of teachers and nurses complaining of leg veins. Crossing your legs regularly may also aggravate the condition, but it isn't a primary etiology.

Telangiectasia and varicosities develop as the internal venous valves we rely upon to force blood flow back to the heart become incompetent and lose the ability to block backward blood flow. The vessels extend and become serpiginous. This backward flow continues through the system into the smaller vessels, which we see clinically arising along arcs of larger vessels.

Typical branched spider veins appropriate for scleropathy.

I warn patients that vessels will recur as long as the underlying reason doesn't change. People whose jobs require long hours standing should wear medical-grade support stockings regularly. I recommend deferring scle-rotherapy if another pregnancy is planned imminently. Keeping leg muscles in motion with exercise aids returning blood flow and improves vessel health. PSP: Sclerotherapy is an art that is very dependent on technique and proper selection of solutions. What solutions and approaches work best for you? Waldorf: I use a 30-gauge needle bent 45 degrees on a 3 cc syringe containing 2 cc's of hypertonic saline. Using a polarized headlamp with magnification, I easily visualize and "cannulate" telangiectasia. I see the bevel of my needle underneath the skin and inject hypertonic saline with very light pressure. To reduce discomfort, I store hypertonic saline for sclerotherapy in the refrigerator, as cold saline tends to hurt less.

I use hypertonic saline rather than Sotradechol, a popular detergent scleros-ing agent, to avoid any risk for allergy. I can treat patients immediately without testing. However, hypertonic saline cannot be "foamed," which is a technique used to increase the sclerosant's effect on larger vessels
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