BROWN MARKS AFTER SCLEROTHERAPY

Following sclerotherapy treatment of surface leg veins it is usual to develop some superficial bruising in the area of treatment. This bruising typically changes in colour from an initial purple discoloration to a brown colour before disappearing over one to two weeks in the same way a bruise from a knock to the leg might resolve.

In a small percentage of patients however, darker brown marks can develop on the skin after sclerotherapy and can persist for a number of months. These brown marks are termed ‘staining’ or ‘post sclerotherapy hyperpigmentation’ and it is estimated that  brown marks that last more than 12 months after sclerotherapy can occur in about 1-2 % of patients. The pattern of brown staining is commonly in the line of the treated vein (linear staining) but circular coin shaped discolouration can also occur (nummular staining).

Biopsy studies have shown that the brown skin discolouration in staining is due to Haemosiderin, which is the iron residue from red blood cells. In staining the Haemosiderin is predominantly found deposited in the superficial dermis of the skin but can sometimes be found deeper. It is thought that when leg veins are injected red blood cells leak from inside the vein into the surrounding skin (extravasation) and then the Haemoglobin in the blood cells is broken down into Haemosiderin. As Haemosiderin is a brown pigment deposits appear as a brown discolouration on the skin with the more Haemosiderin the darker brown the colour.

Various factors have been identified that are associated with an increased risk of staining and include

• DARK SKIN TYPE: Greater risk in darker skin types and this is probably because Haemosiderin can stimulate normal skin pigment cells (melanocytes) to produce more pigment.
• SENSITIVE SKIN TYPE: Some skin types are more sensitive and reactive as suggested by skin that readily flushes and blushes, swells and may develop hives (urticaria). This sensitivity seems to be due to a heightened histamine response in the skin. As histamine can cause increased red blood cell leakage (widens endothelial gaps in wall of blood vessels) the risk of staining.is increased.
• DEEP VEIN REFLUX: If there is pressure from deeper veins pushing blood back into the superficial veins (venous reflux) this can increase leakage of red blood cells into the surrounding skin. This is one of the reasons that if patients have both surface vein and deeper vein problems that the deeper veins are treated first.
• FRAGILE BLOOD VESSELS: Older patients can have more fragile blood vessels that can leak blood cells more readily. In addition older patients can also have a less efficient circulation and blood clearing function. Fragility of vein walls can also be hormonally influenced and in women vein walls can be more fragile for the 2-5 days before their period.
• HIGH IRON LEVELS: If there is a much higher serum Haemoglobin or higher circulating iron levels in the blood this can increase the amount of iron that leaks into surrounding skin. Patients with Iron storage diseases such as Haemochromatosis and those taking high dose Iron supplements can be at an increased risk of staining.
• VEIN PATTERN: Thicker concentrated patches of surface veins are at an increased risk for staining. Staining is also more common on the lower leg, such as shin and ankle, rather than upper leg areas, such as the thigh.
• MEDICATION: The risk of staining is significantly increased in patients taking certain medications, most notably the antibiotic Minocycline. The type of staining that occurs in patients taking Minocycline can be quite significant and is usually a much darker gray to blue-black colour and can persist for years without additional treatment.
• TECHNIQUE: The risk of staining is higher with less experienced doctors performing the sclerotherapy treatment. Excessive injection pressure and excessive concentration of the sclerosing solution are both associated with an increased risk of staining. Choice of sclerosing agent is also important as whilst all sclerosing agents can cause staining the risk is lower with certain products (Polidocanol is the lowest and Hypertonic Saline the Highest).

In patients identified as at higher risk of staining the appropriate use of compression stockings after sclerotherapy treatment is very important to reduce the risk of staining. Compression can help reduce the leakage of blood cells into the surrounding skin and hence lessen the risk of staining. The use of compression stockings is particularly necessary if a decision has been made to treat surface veins in the presence of underlying deeper vein reflux.

In the vast majority of patients who develop staining after sclerotherapy no specific treatment is required apart from encouraging daily massage to the area to help dissipate the unwanted pigment and with time and massage the brown discolouration slowly disappears.

In a small number of patients if they are concerned about the appearance of the staining or it proves very persistent then treatment is possible. Bleaching agents such as Hydroquinone, Kojic acid and Azealic acid target melanocytes and as such are not effective on Haemosiderin pigment. Exfoliants such as chemical peels can sometimes help but carry a risk of causing inflammation and further inflammatory pigment.

The most effective treatment option for removing post sclerotherapy staining is with the use of medical grade lasers. Various lasers have been tried and it has been found that lasers which deliver their laser beam in much shorter pulses are more effective in shattering pigment than lasers that produce longer pulses. The shortest laser pulses are produced by Q Switch nanosecond or picosecond lasers. It has also been determined that light in the 660-680 nanometre wavelength range is particularly attracted to Haemosiderin pigment and lasers that produce laser light in or near this range are the most effective in targeting Haemosiderin.

Hence the laser that is preferred for removing post sclerotherapy staining is either the Q Switch 650nm (REVLITE) or Q Switch 694nm laser (RUBY). The new 755nm picosecond laser (PICOSURE) also seems very effective and is preferred for darker skin types with post sclerotherapy staining as it is less likely to effect normal pigment cells..

At the Melbourne Leg Vein Centre we have all 3 of these lasers available. Although in our clinic the incidence of post sclerotherapy staining that requires laser treatment is very rare, we are often asked to treat patients who have developed staining after sclerotherapy treatments elsewhere.