Spider Veins

Etiology

Spider veins are the result of abnormalities in the horizontal vascular plexus of capillary loops in the skin and can have arterial or venous origins.[3] Venous spider veins are raised, blue or purple, and are often between 1mm and 3mm in diameter. In contrast, those originating from the arterial capillary loops are flat, appear pink or red with a diameter of 0.1mm-1.0mm.[4] In the legs, they are usually about 180 micrometers to 1mm deep in the skin and are composed of a feeder vessel and ectatic venous sprouts found in the reticular dermis.[5] 

The exact pathophysiology of spider veins remains unknown. Some theories have suggested that spider veins arise from varicose veins and are secondary to a similar mechanism of valvular incompetence in chronic venous disease. Interestingly, one study found that only 22.9% of patients with spider veins had evidence of venous incompetence.[6] 

Another theory by Goldman suggested that telangiectasias are the result of local anoxia, which causes inflammation of the endothelium and vascular neogenesis.[7] The pathophysiology may actually be a combination of factors with spider veins being on the milder side of the chronic venous insufficiency spectrum and varicose veins at the more severe end. Incompetent valves in the deep venous network allow retrograde blood flow, and eventually, blood pools in the small superficial vessels. The resultant inflammation and vascular neogenesis from local anoxia cause the small vessels to bulge and branch out, resulting in a spider-like appearance.

Epidemiology

Numerous studies on the epidemiology of spider veins concluded that most adults will eventually develop some form of spider veins during their life. The typical age of presentation is between 30 and 50 years old.[2] Ruckley et al. studied 1566 randomly selected adults in Scotland and reported that 88% of women and 79% of men had spider veins in the right leg.[2] 98% of those affected had very mild symptoms. Chiesa et al. investigated spider veins in 4288 patients and found that women were four times more likely than men to be affected, particularly as gravidity (the number of pregnancies) increased.[8] They also reported that although men were less likely to be affected, their disease manifestation was more serious, and they were more likely to suffer from advanced chronic venous disease. The risk of developing spider veins also increases with obesity and in occupations with prolonged sitting or standing.[9][10] 

Some evidence suggests that smoking is linked to spider veins, and other studies have found that local trauma or a personal history of venous thromboembolism (VTE) increases the risk of developing spider veins in the affected limb.[11][12] Additional risk factors also include genetics and ethnicity, with 90% of people suffering from spider veins having a positive family history, and non-Hispanic whites are at higher risk.[13][14] Other factors predisposing patients to spider veins are the use of topical steroids or female hormones and low fiber diets.[15][16]

History and Physical

Spider veins are predominantly an aesthetic problem. One survey reported telangiectasias of the lower limb as the most concerning cosmetic problem for American women.[7] The majority of patients are asymptomatic; however, a minority of patients who do have symptoms often complain of burning, itching, pain, cramps, or leg fatigue.[7] 

Patients may have one or more mentioned risk factors and could also have a history of chronic venous insufficiency (CVI), including varicose veins or venous eczema. On examination, spider veins can appear as thin blue, red, or purple vessels depending if they are arterial or venous in origin and can be raised or flat. They can form anywhere on the body and at any age, although the majority of patients develop spider veins on their legs and face.

Evaluation

The diagnosis of spider veins is a clinical one based on history and examination. There are no lab tests that are useful in the diagnosis of spider veins. Imaging studies can be helpful in the mapping of the venous system if chronic venous insufficiency is suspected. These include duplex ultrasound, contrast venography, and magnetic resonance venography (MRV).

Spider veins feature on the Clinical, Etiological, Anatomical, and Pathological (CEAP) classification system of chronic venous disease, which describes seven categories (C0 –C7).[17]

• C0 - Absence of venous disease
• C1 - Telangiectasias and larger reticular veins.
• C2 - Varicose veins (diameter of 3 mm or more)
• C3 - Edema
• C4 - Changes in the skin and subcutaneous tissue: pigmentation (C4a), eczema (C4a), lipodermatosclerosis (C4b) or atrophic blanche (C4b)
• C5 - Healed venous ulcer
• C6 - Active venous ulcer

Formally, the definition of telangiectasia is a confluence of dilated intradermal venules of less than 1mm in caliber.[17] Another classification by Redisch et al. describes four types of telangiectasias based on their clinical appearance:[18]

1. Simple linear
2. Spider (radiating from a central locus)
3. Arborizing (arranged like branches on a tree)
4. Papular (discrete round spots)

Treatment / Management

Spider veins are generally harmless and asymptomatic, and the majority of patients seek treatment to reduce or remove them for cosmetic reasons. Treatment includes sclerotherapy, intense pulse light treatment (IPLT), thermocoagulation, and microphlebectomy. Patient factors influence the type of treatments that can be used alone or in combination.

Sclerotherapy

Telangiectasias and reticular veins can be obliterated by injecting sclerosing agents into the vessels. Sclerotherapy is considered to be the first-line treatment for spider veins on the legs. Using ultrasound, the local vasculature is first assessed by examining the deep, superficial, feeder, and perforating veins for obstruction and venous reflux/incompetence. Pathways with an abnormal flow are identified, and the target vessels requiring treatment are marked. The sclerosing agent, which can be a liquid or foam, is injected using a very fine needle (30 gauge) under ultrasound guidance. The agent acts by causing endothelial damage, which leads to vessel fibrosis and an arrest of blood flow. There are numerous sclerosing substances that are currently used in sclerotherapy, and they are classified as detergents, osmotic or chemical irritants.

Detergents such as polidocanol and sodium tetradecyl cause endothelial injury by altering the surface tension around the endothelial cells. Chemical irritants achieve their effect through cauterization; examples include chromated glycerin. Osmotic agents dehydrate endothelial cells. Examples include hypertonic saline and dextrose. In larger reticular veins, foam sclerotherapy may be more appropriate. Foam sclerotherapy involves mixing a fluid such as polidocanol or sodium tetradecyl sulfate with gas to produce the foam. Over time, the vessels fade, are resorbed, and disappear. However, the treatment does not stop new vessels from forming, and multiple treatments may be required to achieve the desired effect. Sclerotherapy is a popular method of treating spider veins, and some studies have reported good improvement in 50% - 70% of patients.[19] Common side effects of sclerotherapy include transient hyperpigmentation, ulceration, sloughing, allergy, thrombophlebitis, swelling, and pain. More serious but rare adverse effects include thromboembolic events, anaphylaxis, and transient visual disturbance. (A1)

Laser Treatment and Intense Pulsed Light (IPL) Treatment

Laser and IPL therapy are non-invasive methods of treating spider veins that have a diameter of less than that of a 30-gauge needle. It is also an option for patients who have spider veins on the face and thus not amenable to sclerotherapy. Patients who are allergic to sclerosing agents or who are needle phobic may also be offered this treatment.

A basic appreciation of laser theory is essential to understand the suitability, limitations, and side effects of this treatment. Laser therapy is delivered via a hand-held device and relies on the target heating up by absorbing energy from photons in the laser. The target will only absorb the photon energy if the laser wavelength matches the chromophore of the target, i.e., the target must be of the appropriate color. It follows that by varying the wavelength of the laser, different chromophores (and therefore different structures) can be selectively targeted while avoiding damage to surrounding tissues.

In spider vein therapy, the light energy is absorbed by hemoglobin in the damaged vessels. The vessels heat up and occlude secondary to thrombus formation by photocoagulation. This concept of selective photolysis was developed by Anderson and Parrish in 1983 and remains the basis of laser therapy in medicine today.[20](B3)

A variety of different lasers are available for the treatment of spider veins, each with their advantages, drawbacks, and specific use.

Argon Laser

Argon lasers were one of the first lasers used for vascular purposes. These lasers produce a blue-green wavelength in the range of 488nm and 514nm. This wavelength means it is well absorbed by hemoglobin and can easily penetrate 1mm into the skin. Some studies have reported success rates of 90% when used in conjunction with sclerotherapy.[21][22] However, argon lasers pose a higher risk of scarring and pigmentation; this is probably the result of their non-specific thermal injury.[22]

Pulsed Dye Laser

Pulsed dye lasers, with long wavelengths of 595nm and extended pulse duration of 40ms, have proved useful in the treatment of spider veins.[23] Modern pulsed dye lasers have an integrated cooling device and use pulses shorter than the relaxation time of small vessels (1ms). These characteristics help reduce the risk of unintended thermal damage to surrounding structures, thus reducing scarring and pigmentation. Pulsed dye lasers have shown good clearance with small-caliber vessels; however, their performance with larger caliber vessels has not been as promising.[24][25]

Neodymium YAG Laser

The longer wavelength of 1064nm of neodymium:YAG (Nd:YAG) lasers make them suitable for larger caliber veins. They are one of the most efficacious lasers in spider vein therapy but may not be the most popular amongst patients due to the discomfort they cause. In addition to the increased pain levels, Nd:YAG lasers can also cause hyperpigmentation.

Potassium-titanyl-phosphate (KTP) laser

Potassium-titanyl-phosphate (KTP) lasers double the frequency of Nd:YAG lasers by passing the light through a KTP crystal. The resultant light is in the wavelength range of 532nm to 1064nm. This higher frequency makes them suitable for darker skin patients and smaller vessels. They are commonly used on the face as they have limited penetration but are not as efficacious for leg spider veins.

Pulsed Diode Laser

Pulsed diode lasers emit photons in the range of 800nm to 900nm. These lasers have an excellent safety profile, which is partly the result of the cooling devices they are equipped with and the fact that they cause minimal inflammatory changes. Pulsed diode lasers have also shown high clearance rates on leg spider veins in numerous studies.[26][27](A1)

Overall, lasers are safe and efficacious methods of treating spider veins. They are non-invasive and are a popular choice for patients with face spider veins or who are needle phobic. Other side effects of laser therapy include blistering, crusting, swelling, and spotting. Contraindications to laser therapy include pregnancy, blood-thinning medication, photosensitive or hypertrophic/keloidal scarring disorders, untreated varicose veins, and in some cases, recent tanning or dark skin type. Patients are instructed to omit aspirin, nonsteroidal anti-inflammatory drugs, or blood thinners before the procedure and for 48 hours afterward. 

Microphlebectomy

Microphlebectomy uses hooks for venous extraction via minute skin incisions (1-3mm) or needle punctures. Microphlebectomy avoids the complications of other treatments such as scarring, skin necrosis, and residual hyperpigmentation.[28]  

Thermocoagulation

Similar to other methods of treatment, thermocoagulation achieves its effect by causing endothelial damage to the target vessel. The heat generated from a very high frequency (radio frequency) pulse is transmitted to the vessel through a very small needle inserted into the target vessel. When the temperature reaches 70 degrees Celsius, the vessel is occluded through thermocoagulation. The vessel is eventually resorbed and fades away.

Differential Diagnosis

Spider veins can be associated with CVI, and other stigmas of CVI, such as varicose veins, venous eczema of the skin, stasis dermatitis, and leg ulcers may be present.[29][30] These conditions are more severe and warrant medical attention before addressing spider veins, which are often purely a cosmetic problem. Spider veins cans can also be an early sign of CVI, and clinicians must be weary of undiagnosed CVI in patients presenting with spider veins.

Spider angiomas can also masquerade as spider veins. They are harmless, but they often herald more serious systemic diseases such as rheumatoid arthritis, thyroid, and liver disease.[31] They have a similar appearance to spider veins, with the exception that they have a central red spot with radiating web-like extensions.

Prognosis

Untreated spider veins remain a purely cosmetic issue and do not cause any significant medical problems or functional impairment. In severe cases affecting the legs or face, they can affect the patient’s self-esteem and lead to psychological issues, particularly in young females who are more body-conscious.

Complications

Complications from untreated spider veins are infrequent and do not usually cause any health problems. In severe cases associated with varicose veins, there is a higher chance of developing sores or skin ulcers, and thrombophlebitis. As with any procedure, there are risks of complications, and therapeutic procedures for spider veins are no exceptions; however, these risks are very low.