Sclerotherapy (injection techniques) for spider veins on the legs

Schwartz L, Maxwell H

Published Online:

December 7, 2011

Spider or thread veins (telangiectasias) are small superficial veins that widen and become visible, often on the legs. They are sometimes, but not always, associated with chronic venous disease affecting the deeper veins. Risk factors for developing spider veins include a family history, pregnancy, taking female hormones, topical steroid use, local trauma, and prolonged sitting or standing. Some people experience pain, cramps, burning, throbbing, itching or leg fatigue, and women in particular may be concerned about the cosmetic appearance. People are increasingly seeking treatment.

Sclerotherapy has been used for centuries to treat spider veins. The technique involves the injection of a chemical into the veins. This is sometimes followed by compression with bandages or stockings.

The liquid or foam sclerosing agent is injected into the vein to cause localised damage to the inner lining (endothelium) of the vein. This leads to inflammation, a blood clot, collapse and thickening or scarring of the vessel. The blood stops flowing and the vein loses its red or purple appearance. There is currently no agreement about which sclerosing agent is most effective with the fewest side effects and least discomfort to patients.

We included 10 randomised controlled trials involving 484 people in our review. Sodium tetradecyl sulfate (STS), polidocanol (POL), and heparsal (20% saline mixed with heparin 100 units/mL) cleared the veins more effectively than an injection of normal saline. There was no evidence that one agent was better than any other sclerosant, that patients were more satisfied with one agent than another, and which dose of an agent was best. There was some evidence that POL was less painful than heparsal and STS, and that STS was more painful than heparsal. At higher doses, some of the agents appeared to cause more pain and side effects such as mild brown discoloration, a flare or blush next to the injected vein, or itching; however, we do not have enough evidence to determine the optimal concentration to use. The trials were designed in very different ways and used various agents, which meant we were unable to combine the studies to help form firm conclusions. The amount of available evidence was limited and the overall methodological quality of the research was poor, as was the quality of reporting.

Abstract (click to read)

Background:

Sclerotherapy has been used in clinical practice for centuries, but there is still no consensus about which, if any, sclerosing agent provides the best results.

Objectives:

To assess the effectiveness and safety of sclerosing agents in the treatment of telangiectasias of the lower limbs.

Search strategy:

The Cochrane Peripheral Vascular Diseases (PVD) Group searched their Specialised Register (last searched 26 May 2011) and CENTRAL (2011, Issue 2). We searched references within identified studies and from the Cited References in the Web of Science. We contacted study authors and pharmaceutical companies. There were no language restrictions.

Selection criteria:

We included randomised or quasi-randomised controlled trials on the treatment of telangiectasias comparing sclerotherapy with a normal saline placebo, no treatment or an alternative sclerotherapy regimen.

Data collection and analysis:

Both authors determined which studies to include, extracted the data and rated risk of bias. One author (LS) contacted study authors and pharmaceutical companies and analysed the results.

Main results:

Ten studies involving 484 patients were included. There was no evidence suggesting superior efficacy of any one sclerosant over another, but there was evidence of superiority of sclerotherapy to placebo.

The evidence did not suggest an increase in patient satisfaction with any one agent versus another, but there was evidence that patients were less satisfied with placebo.

There was some evidence suggesting that polidocanol (POL) was more likely to cause adverse reactions at a concentration of 1% compared with lower concentrations or hypertonic saline, and that sodium tetradecyl sulfate (STS) was more likely to cause adverse reactions at a concentration of 1% compared with POL at 0.5%.

There was some evidence suggesting that STS was more painful than POL, heparsal (20% saline mixed with heparin 100 units/mL) or placebo, and that POL was no more painful than placebo. Evidence from one study suggested that hypertonic saline (HS) was more painful than POL.

The data were not suitable for meta-analysis.

Authors' conclusions:

The evidence did not suggest superior efficacy or patient satisfaction for any one sclerosing agent used in the treatment of telangiectasias of the lower limbs, but the agents studied showed superiority to a normal saline placebo. However, the amount of available evidence in this field is small and the overall methodological quality of the research was poor, as was the quality of reporting. More research is needed to determine the optimal agent(s) and the ideal dosing to achieve the best results and maximize patient satisfaction. Future research efforts should incorporate more demographic data and symptom measures to allow for comparison with findings from observational studies, thereby aiding assessment of how various risk groups respond to treatment.

This record should be cited as:

Schwartz L, Maxwell H. Sclerotherapy for lower limb telangiectasias. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD008826. DOI: 10.1002/14651858.CD008826.pub2

Assessed as up to date:

May 26, 2011

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Primary Review Group:

Peripheral Vascular Diseases Group

Health topics:

Heart & circulation > Varicose veins

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Sclerotherapy (injection techniques) for spider veins on the legs

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