Aesthetic Vascular Surgery – Spider Veins

In brief

Spider veins (telangiectasias) and their slightly larger cousins, reticular veins, are among the most common vascular findings in adults. They are usually benign, but they can be cosmetically distressing, sometimes cause aching or burning, and occasionally signal underlying venous reflux that needs to be found and treated first. Good outcomes depend on assessing the whole venous system before treating the visible veins.

What they are

• Telangiectasias (spider veins): intradermal venules under 1 mm, red, blue or purple, in linear, arborising or “starburst” patterns. This is CEAP class C1.
• Reticular veins: blue-green subdermal veins of 1–3 mm. These often feed the telangiectasias above them.

How common, and why

Population studies such as the Edinburgh Vein Study found telangiectasias and reticular veins in a large majority of adults, and they are more frequent in women. Contributing factors include:

• Family history (strong genetic component)
• Female sex hormones, including pregnancy, the oral contraceptive pill and HRT
• Age, and prolonged standing occupations
• Sun-damaged skin and rosacea (facial telangiectasias)
• Previous trauma, surgery or sclerotherapy (matting)
• Underlying venous reflux, in a minority of patients

Presentation and examination

Most patients present with appearance concerns. Some report aching, heaviness, burning or itch, though the link between spider veins and symptoms is inconsistent, so look for another cause of the symptoms.

Examine the patient standing, with good lighting (a transilluminator or vein-light helps). Check for:

• Reticular feeder veins
• Varicose veins
• Corona phlebectatica at the ankle
• Oedema, pigmentation and lipodermatosclerosis
• Distribution: telangiectasias over the lateral thigh, buttock, vulva or perineum raise the possibility of a pelvic venous origin

Investigations

Ask for a venous duplex ultrasound in these cases:

• Symptoms out of proportion to the veins
• Visible varicose veins
• Signs of chronic venous disease
• A family history of significant venous disease
• Recurrence after treatment
• A distribution suggesting pelvic or perineal origin

A purely cosmetic C1 presentation without symptoms or signs does not always need imaging. A low threshold for duplex is reasonable in a specialist setting.

Management

Conservative. Graduated compression may relieve symptoms, but it does not remove spider veins. Sun protection, weight management and exercise help general venous health but will not clear existing veins.

Treat underlying reflux first. If duplex shows great or small saphenous or perforator reflux, treating the source (endovenous ablation, foam sclerotherapy or ambulatory phlebectomy as appropriate) reduces recurrence and improves the cosmetic result.

Definitive treatment of the visible veins

Option	Best for	Notes
Liquid sclerotherapy (polidocanol or sodium tetradecyl sulfate)	Telangiectasias, small reticular veins	First-line for most patients. Very low concentrations are used for the finest veins.
Foam sclerotherapy	Reticular veins, larger feeders	Stronger effect, so use a small volume and take more care with visual and neurological symptoms.
Transcutaneous laser or IPL (Nd:YAG 1064 nm, pulsed dye, KTP)	Very fine vessels, needle-averse patients, matting, facial and ankle veins	Higher rates of pigmentary change and burns in darker skin types. Less effective for larger vessels.
Ambulatory phlebectomy	Larger reticular veins	Small incisions or punctures under local anaesthetic.
Combined (sclerotherapy plus laser)	Resistant or extensive disease	Treat feeders first, then the fine surface network.

Practical points

• Expect 1-2 sessions, spaced 4–6 weeks apart depending upon number of veins
• Compression stockings after treatment, typically two weeks (daily application).
• Walking is encouraged; avoid intense exercise, heat and sun exposure for a period of 2 weeks after treatment.
• Complete clearance is not guaranteed. Most patients achieve substantial improvement, but new veins can appear over time and maintenance treatment is common.
• Treatment is usually cosmetic and generally not Medicare-rebatable unless there is symptomatic or significant venous disease requiring intervention.

When to wait: defer treatment in pregnancy (usually until after delivery and breastfeeding), acute DVT, active skin infection, known sclerosant allergy and severe immobility. Take extra care in patients with migraine with aura or a known right-to-left shunt.

Outcomes and natural history if untreated

Untreated spider veins are not dangerous. They tend to persist or slowly increase in number, especially with hormonal change and age. Bleeding is rare. The main clinical importance is as a marker of underlying reflux in the minority of patients who have it.

Complications and side effects

Treatment	Common	Uncommon	Rare
Sclerotherapy	Stinging, cramping, bruising, urticarial wheals, temporary swelling	Hyperpigmentation 1-3% (usually fades over months, occasionally persists), telangiectatic matting, superficial thrombophlebitis or trapped blood	Skin ulceration or necrosis (extravasation, intra-arterial injection), visual disturbance or migraine, anaphylaxis, DVT, TIA or stroke (mainly foam)
Laser/IPL	Redness, swelling, purpura	Blistering, crusting, hyper- or hypopigmentation	Scarring, burns
Phlebectomy	Bruising, tenderness	Haematoma, hyperpigmentation	Nerve injury, infection

Key points

• Most spider veins are benign and cosmetic; a focused venous history and examination will identify those that are not.
• Refer for duplex and specialist assessment if there are symptoms, varicose veins, skin changes, recurrence, or a pelvic or perineal distribution.
• Treating source reflux first improves outcomes.
• Counsel patients that treatment improves but does not “cure” the tendency to form new veins.
• Sclerotherapy is safe in experienced hands, but pigmentation and matting are the complications patients most often complain about, so warn them before they consent.

This page is general information and does not replace individual medical advice.