What is Sclerotherapy?
Sclerotherapy is the use of an injection technique as a method of treating a vein. The term comes from the word ‘scleros’ meaning to seal off, and ‘therapy’ which means to treat. Essentially a needle is inserted into a vein and a small amount of a solution is injected into the vein which damages the inside of the vein causing the vein to collapse and seal off. The body then breaks down the treated vein in much the same way the body removes bruises.
Sclerotherapy can be used on veins in various areas of the body including for haemorrhoids and for treating veins in the oesophagus, but by far the commonest use of the technique is for treating leg veins. When treating leg veins sclerotherapy can be used to directly inject veins visible on the surface of the skin, when it is termed surface sclerotherapy or microsclerotherapy (in reference to the very fine needles that are used). When sclerotherapy is used to treat veins below the surface of the skin, it requires an ultrasound to visualise the veins as they are being injected (ie so the doctor can see where the injection is being placed). This deeper injection is termed Ultrasound Guided Sclerotherapy (UGS). (SEE UGS)
What are the advantages of Surface Sclerotherapy?
The main advantage of using sclerotherapy to treat surface veins is that in the vast majority of patients it is the most effective method. In the treatment of surface veins the main alternative is Surface Laser which is really limited to only the smallest of surface veins whereas sclerotherapy can target both small and large surface veins. Sclerotherapy is a much less expensive option than laser as it doesn’t require expensive laser equipment. After sclerotherapy there is usually less discomfort than post laser (when there can be a burning sensation) and the rates of side effects such as skin pigmentatation are less than post laser. Sclerotherapy patients can have sun exposure immediately after treatment whereas laser treated patients may need to avoid direct sun on the treated area for several weeks.
What are the disadvantages of Surface Sclerotherapy?
Sclerotherapy is a much more technically difficult procedure to perform than laser. It requires extensive experience and skill to perform well. This is why it is important that patients look for specialist doctors with an established reputation in sclerotherapy . If the surface veins are so small that an experienced sclerotherapist cannot get the needle into the vein then laser would need to be considered. Sclerotherapy does involve a needle, and even though it is tiny and doesn’t hurt, there are a small number of patients who are ‘needle phobic’ and even the thought of a needle can be overwhelming. Sclerotherapy does involve injecting a solution into the vein and, albeit rare, some patients can be sensitive or allergic to the solution.
What is the Sclerotherapy solution that is used?
In Australia, there are 3 different solutions that have been approved by the TGA (Therapeutics and Goods Administration) for use in sclerotherapy. These approved solutions are Hypertonic Saline (20%), Aethoxysclerol and Sodium Tetradecyl Sulphate(STD). At the Geelong Laser Medical Centre we use all three of the approved solutions at varying concentrations in both liquid and foam preparations.
For the majority of surface veins we use Aethoxysclerol at varying strengths (0.5% -3%) dependent on the size of the veins we are treating. For the majority of deep veins we use the STD solution in both liquid and foam form.
Is Surface Sclerotherapy painful?
The actual sclerotherapy injection is not painful because the needle used is extremely fine (30 or 32 gauge) and the majority of patients find the whole procedure very straight forward. For the small number of patients who notice discomfort when the actual solution is injected, we have found that by using a particular saline to dilute the solution, the procedure is then very well tolerated.
However, we do recommend for women with more sensitive skin, that they do not schedule a sclerotherapy treatment in the immediate premenstrual time when they can have heightened skin sensitivity. For patients who are more sensitive, taking an anti-inflammatory such as Nurofen before treatment can also be beneficial.
Are there any side effects?
Large clinical trials over many years throughout the world have found Surface Sclerotherapy to be a remarkably safe and well tolerated method for treating leg veins. It does need to be remembered that whilst side effects might be rare, unknown or unpredictable problems can occur with any medical treatment. The main side effects are:
- Bruising. Superficial bruising can occur after treatment but can be minimized by the use of compression hosiery.
- Tender Cords. When larger veins are treated tender cords can develop which represent trapped blood, these gradually disappear over several weeks. Massage commencing a week after treatment can help to clear these small lumps, but if persistent they can be released by aspiration with a small needle in our rooms.
- Pigmentation. Uncommonly the treated area may develop a brownish discoloration a few weeks after treatment. This is similar to how a bruise goes a brown colour before it disappears and represents the iron part of the blood (haemosiderin). It is more common if very large or thick patches of veins are treated, in darker skin types, in patients with iron storage conditions (eg haemachromatosis) or if there is untreated underlying deep vein problems (ie venous reflux). It usually slowly resolves especially with massage but should it persist and be a cosmetic concern it can be removed with laser treatment ( usually Q Switch 694nm or Q Switch 650nm lasers).
- Infection. As with any injection a skin infection is possible as the skin’s surface is being broken, but these are very fine needles, the needles are sterile and single use, the solution is sterile and aseptic technique is used. Sclerotherapy should not be performed through skin with any active skin disease in the treatment area.
- Ulcer. A rare complication is a small skin ulcer. If it occurs it is mainly in the elderly where the arterial circulation may not be as good. These small ulcers typically heal well.
- Allergy. Allergic reactions to the solutions are possible but very rare. The incidence is probably so low because the sclerotherapy solutions work by shutting down blood vessels and working locally in the treatment area ie they do not work by spreading through the body. If someone is allergic to a sclerotherapy solution we can use an alternative solution or consider laser.
- DVT. This is not a concern with the smallest of surface veins, however the larger the veins and the deeper the veins that are treated the more we need to be aware of this rare but possible complication. All patients, irrespective of the size of the veins treated, are instructed to walk for 30 minutes immediately after sclerotherapy, then each day for the 2 weeks after sclerotherapy. The use of compression stockings is also important in reducing DVT risk by promoting blood flow through the deeper veins and generally, the larger the veins treated the longer the need to wear stockings. Patients identified as being at higher risk of DVT may need to have a special preventative anti-coagulant injection (Clexane).
Who does the Surface Sclerotherapy?
How many treatments are necessary?
This depends on the size, type and number of veins and the desired level of improvement. Patients with surface veins typically have 3 or 4 treatments spaced a minimum of 4 weeks apart. Some patients may only require 1 or 2 treatments whilst others with extensive surface veins on both legs may require a longer series of treatments.
It needs to always be kept in mind that if you have a tendency to get leg veins in the first instance, you will still have a tendency to get more leg veins in the future. The aim of treatment should be to get as big an improvement as possible with as few treatments as possible and then have follow up maintenance treatments in the future. Maintenance treatments may be once a year or several years apart, it depends on the rate at which new veins appear and how much they concern the individual patient.
What are the costs?
What happens after treatment?
Immediately after treatment you will have some small tapes that need to stay on for 1-2 hours and some stockings that will need to be on for anywhere from 2 days to 2 weeks depending on the type of veins treated. You will be instructed to walk 30 minutes immediately after treatment and then a continuous daily walk of 30 minutes for the 2 weeks after treatment.
Normal activity and work can be resumed immediately after treatment. It is preferable that vigorous exercise that involves repetitive pumping of your legs (eg aerobics, running) is avoided for at least 48 hours after treatment to minimize bruising.