What is Sclerotherapy?
Sclerotherapy is the use of an injection technique to treat a vein and can be used in reference to injecting veins anywhere on the body. Whilst sclerotherapy has been used to treat bleeding veins in the oesophagus (oesophageal varices), for shrinking haemorrhoids and for treating veins on the chest and arms, the commonest use by far is in the treatment of leg veins.
Both small spider veins and large Varicose Veins can be treated by sclerotherapy and leg veins can be targeted both on the surface of the skin or deep below the surface. The term sclerotherapy is derived from ‘skleros’ which in Greek means hard and has come about because after a vein is injected the vein seals off and goes hard before the body breaks it down.
What is Surface Sclerotherapy?
When sclerotherapy is used to directly inject veins visible on the surface of the skin it is termed surface sclerotherapy. The term microsclerotherapy is sometimes also used to emphasise the very fine needles that are being used, typically 30 gauge but sometimes 32 gauge needles which are similar to the thickness of acupuncture needles.
What is Cold Sclerotherapy?
Cold Sclerotherapy, also called cryosclerotherapy, is a method of sclerotherapy that uses cold air onto the skin both before and during sclerotherapy. The purpose is to reduce any discomfort associated with the procedure rather than any enhanced results. The use of cold air cooling is not new and has been used for many years with heat based treatments notably laser treatments. Cold sclerotherapy can be worth considering if a patient has particularly sensitive skin but is not a widely used procedure.
How is Sclerotherapy performed?
Sclerotherapy is a walk in walk out office procedure performed in the clinic rooms. No anaesthetic is required and normal activity and work can be resumed immediately afterwards. The treatment takes about 30 minutes and involves multiple small injections. A stocking is usually required after treatment and a walk for 20-30 minutes after treatment is usually recommended.
How does Sclerotherapy work?
Essentially a needle is inserted into a vein and a small amount of a solution (which is called a Sclerosant) is injected into the vein. The solution is salt based and causes damage to the inside of the vein causing the vein to collapse and seal off. The body then breaks down the sealed off (sclerosed) vein in much the same way that the body breaks down and removes bruises.
What is the Sclerotherapy solution that is used?
In Australia, there are 3 solutions that have been approved by the Therapeutic Good Administration (TGA) for use in sclerotherapy treatments. These solutions are called sclerosants and the approved solutions in Australia are Aethoxysclerol, Hypertonic Saline, and Sodium Tetradecyl Sulphate. These solutions can be used at varying concentrations and can be formulated as either liquid or foam preparations.
For the majority of surface veins Aethoxysclerol at varying strengths (0.5% -3%) dependent on the size of the veins is the most commonly used sclerosant.
Is Surface Sclerotherapy painful?
The needle used in Surface Sclerotherapy is extremely fine, usually 30 gauge or 32 gauge, which is like an acupuncture needle and the majority of patients do not find this painful. Some patients do complain of some discomfort when the sclerosant solution is injected and if this happens the use of preserved saline can reduce the discomfort.
For patients with more sensitive skin, taking an anti-inflammatory such as Nurofen sixty minutes before sclerotherapy treatment can reduce any discomfort. In women with more sensitive skin, we recommend they do not schedule sclerotherapy treatments at times such as premenstrual when there can be heightened skin sensitivity.
What are the advantages of Surface Sclerotherapy?
In the vast majority of patients Surface Sclerotherapy is the most effective method for treating surface veins. The alternatives of Surface Laser and Surface Radiofrequency are limited in effectiveness to only the smallest of surface veins. Surface Sclerotherapy can target both small and large surface veins at the same time and is the most cost effective option as expensive laser and radiofrequency equipment is not required.
Following Surface Sclerotherapy there is less discomfort than after heat based treatments such as laser where there can be a burning sensation. The incidence of skin side effects such as pigmentation are higher with laser treatment and also after Surface Sclerotherapy patients can have sun exposure whereas after laser patients need to avoid direct sun exposure to the treated area for several weeks.
What are the disadvantages of Surface Sclerotherapy?
The main disadvantage of Surface Sclerotherapy is that it is technically much more difficult to perform than laser and requires extensive experience and skill for optimal results. Also Surface Sclerotherapy does require the use of a needle, and despite the fact the needles used are very small and not painful, there are a small number of patients who are ‘needle phobic’ and can’t cope with the thought of any needles and laser may need to be considered in this situation.
Whilst the solutions used for Surface Sclerotherapy are well tolerated and regarded as very safe they are not recommended for use during pregnancy and there are also rare cases of patients being sensitive or allergic to a sclerosant solution which means that solution needs to be avoided.
Are there any side effects?
Surface Sclerotherapy has been shown to be a remarkably safe and well tolerated treatment in a large number of clinical studies throughout the world. Whilst significant side effects with Surface Sclerotherapy are rare, it needs to always be kept in mind that unknown or unpredictable problems can occur with any medical treatment.
Side effects with Surface Sclerotherapy are mainly local and include:
(1) Superficial Bruising. This is minimised by use of compression stockings and typically resolves over 1-2 weeks
(2) Tender Lumps. This represents trapped blood inside the vein and occurs more when larger surface veins are injected. Can take a number of weeks to resolve but if persistent can be treated by aspirating or massage.
(3) Brown Discolouration. This represents the iron part of the blood (haemosiderin) and can occur in patients with darker skin types and also if there are untreated problems with deeper veins. In rare cases when pigmentation persists for several months laser treatment with Q-Switch lasers can break this pigment down.
(4) Skin Infection. Any injection technique can be complicated by infection as the skins surface is being broken. Fortunately with sclerotherapy skin infection is very rare due to the fine single use sterile needles and the sterile saline solution that is used.
(5) Skin Ulcer. Can rarely occur in elderly patients when arterial circulation is not as good. Typically if skin ulcer develops after sclerotherapy it is small and heals well over a number of weeks.
(6) Matting. Is a reddening in the area of treatment due to inflammation. Is quite uncommon and typically resolves over time but on occasion improvement can be hastened with laser treatment.
Systemic side effects such as allergies, are possible with any medication, but the incidence with sclerosant solutions is very rare which is probably because the solutions work by shutting down blood vessels rather than spreading through the body. If a patient is allergic to a sclerosant either an alternative solution needs to be used or laser treatment considered.
Deep Vein Thrombosis (DVT) is more of a potential risk when deeper and larger veins are treated, however anytime veins are treated we need to be aware of the possibility of this complication. The use of compression stockings after treatment and regular, daily walking in the 2 weeks after treatment are regarded as important preventative measures. Patients identified as at higher risk of DVT may need to have preventative blood thinning injections (Clexane).
Who does the Surface Sclerotherapy?
Surface Sclerotherapy treatments are performed by medical practitioners with extensive experience and training in the latest leg vein treatments.
How many treatments are necessary?
The number of Surface Sclerotherapy treatments varies depending on the severity of the surface veins and how much improvement is required. Most patients need about 3-4 treatments which are spaced at least 4 weeks apart. Some patients may only require 1-2 treatments whilst others may need more than 6 treatments.
The emphasis in Surface Sclerotherapy treatments is to get as big an improvement as possible with as few treatments as possible, and then have follow up maintenance in the future if needed. It needs to be remembered that if there is a genetic tendency to develop surface veins in the first instance, there will be a genetic tendency to develop more veins in the future whether the existing surface veins are treated or not.
What are the costs?
The costs of Surface Sclerotherapy treatment will be fully discussed at the initial ‘Leg Vein Consultation’ but there will be some out of pocket expenses. Medicare will only provide a rebate for surface sclerotherapy if the veins are over a certain size (greater than 2.5 mm).
If there is no Medicare rebate then the Government will also charge GST of 10%. There is no Medicare rebate for the laser or radiofrequency treatment of surface veins. Private health insurance funds may provide some rebate for compression stockings but do not provide any rebate for out of hospital procedures such as sclerotherapy treatments.
What happens after treatment?
After Surface Sclerotherapy treatment there will be some small tapes on the skin that need to stay on for at least 1-2 hours. Compression stockings will be required to be worn for anywhere from 2 days to 2 weeks depending on the size of the veins, with larger veins requiring compression for longer.
After sclerotherapy treatment walking is important for at least 20-30 minutes after treatment and daily for the next 2 weeks. Whilst normal walking, working and standing can be resumed immediately after treatment it is preferable to avoid vigorous exercise that involves pumping of the leg muscles for at least 48 hours, to minimise bruising and to improve results.