Spider (Thread) Veins

Spider veins are different to varicose veins. Whilst Varicose Veins are the larger “knobbly” veins that protrude under the skin, spider veins are fine veins that are within the surface layers of the skin.  Spider veins occur for several reasons but the commonest of which is back pressure in the skin veins from underlying hidden abnormal or varicose veins. These abnormal veins may be small “reticular” veins such as those often found on the outside of the lower leg or thigh, or full-blown varicose veins that often feed spider veins on the inside of the thigh and ankle. 

Whilst there is an identifiable cause for most thread veins, some people have spider veins with no underlying cause, these are known as idiopathic telangiectasias. Thread-veins around the ankle (typically caused by underlying varicose veins) are known as Corona Phlebectatica. This condition is usually caused by an underlying varicose vein problem can be a warning sign that you are at risk of developing a leg ulcer in this area.

Figure 2 - An example of a patient with Corona Phlebectatica around the inside ankle due to underlying reflux.

The only way to diagnose underling cause of the spider veins (either varicose veins or reticular veins) is by an examination with venous duplex ultrasound. This is an ultrasound scan that specifically looks at the veins in your legs and how they are working. It is called duplex ultrasound because it uses 2 modalities, one known as B-Mode Ultrasound to generate a 2d picture of the anatomical structures and Doppler ultrasound (colour or pulse waved doppler) to look at the flow of blood within the veins.

Correctly diagnosing and treating the underlying cause of the thread veins significantly reduces the chance of recurrence of the veins. It also helps to prevent complications such as excessive skin staining and telangiectatic matting. Telangiectatic matting is a condition where a large number (or mat) of very fine thread veins forms around a treated area. This can be unsightly and difficult to treat with injections as the veins are so fine and this may need laser, short wave diathermy or cryotherapy treatments to correct.

For most people, thread veins are mainly a cosmetic problem as they are uncomfortable with the appearance of these veins. This can lead to patients avoiding wearing certain clothes or even avoiding going out.  For these people, the veins can be left untreated and will slowly progress over time, or alternatively, it is perfectly reasonable to treat their veins to improve the look and feel of their legs. Patients wanting veins treated for purely cosmetic reasons should ensure that they have carefully considered the risks, benefits, and costs of the treatment, and had all their questions fully answered before proceeding. Concerns about appearance is the commonest reason for patients to consult with me about thread veins, and the commonest reason for treatment.

Occasionally, patients develop thread veins that are bleeding or painful. Bleeding thread veins, especially around the ankle can be a medical emergency and is the only criteria to allow thread vein treatment on the NHS. These veins should be injected urgently to prevent further bleeding, this should be done by the NHS (via GP or A+E).

Classically thread veins are said not cause pain, and therefore if you have a patch of thread veins associated with pain it is very important that we do a careful examination to rule out other causes. Other causes for the pain include nerve pains from the back, arterial or varicose vein related issues or musculoskeletal causes. Having said that, I have seen several patients over the years, who had thread veins with associated pain that resolved completely after sclerotherapy treatment. At present, painful veins (including thread veins) is not a clinical commissioning group criteria and so patients cannot access treatment for painful veins on the NHS unless they have other issues such as bleeding or ulceration.

Figure 3 - An example of extensive ankle blue veins (Corona Phlebectatica) with visible feeding varices (Varicose Veins) at risk of bleeding. Note simple uncomplicated spider veins have a very low risk of bleeding.

Unfortunately, there is no evidence that using compression socks or stockings can help reduce or prevent the progression of thread veins. Whilst they do not prevent progression, stockings can be helpful for reducing general swelling and relieving tired achy legs. Stockings can be purchased from any good local pharmacy or online via a reputable retailer such as Daylong.

As an alternative, if the distribution of the veins is below the knee, then simple sports compression hosiery, can be more comfortable and very effective. I often wear this type of stocking when I stand at work for prolonged periods or operate. These can be purchased from any sports retailer or online.

Figure 4 - An example suitable sports compression socks (they come in multiple colours and styles), these are rated at 20-30mmHg which is the same as class II medical compression stockings, many patients report that this type of stocking is easier to put on and more comfortable and wear. 

Concealment

Some patients decide to continue to live with their thread veins and use camouflage creams or fake tan products to reduce their appearance. Tattoo or scar concealer products can be very effective if correctly matched to your skin tone. Apart from a very few (rare) exceptions such as bleeding, this is a safe strategy.

Topical Creams

There are numerous topical creams currently available that claim to treat thread (spider) veins. Almost all contain at least one of the following active ingredients:

•  Butcher’s Broom (herbal extract) - is claimed to reduce swelling and inflammation as well as strengthening and toning veins.
• Chestnut (herbal extract) – similar to Butcher’s Broom is claimed to reduce inflammation and strengthening blood vessel walls and disguise the appearance of spider veins.
• Retinol (vitamin) - Retinol is derived from vitamin A and is claimed to treat other skin conditions such as wrinkles, fine lines, large pores and acne. Some creams containing retinol also claim to treat spider veins.
• Vitamin K - This vitamin is an important part of the clotting cascade. Creams containing vitamin K may also claim to be effective in diminishing the appearance of spider veins.

However, while you may notice a small improvement with the use of these creams, the effects will be temporary.

Micro-Sclerotherapy

Figure 5 – Mr Rob Windhaber injecting spider veins in a patient who had underlying varicose veins. Note that initially the veins disappear as all the blood is displaced by the sclerosant.

This is by far the most effective treatment for the majority of patients with leg spider (thread) veins. Using a syringe and a tiny needle, a small amount of sclerosant solution is injected into the thread vein to empty it of blood.

The solution is a special form of detergent that removes the lining of the vein and causes the vein walls to become irritated and stick to itself, closing it shut and preventing it from filling up with blood again. 

Sometimes a single injection will remove more than one vein, but it is common to need several injections to clear all the veins, and some veins may need injected on more than one occasion.

The limit to the number of injections that you can have in a single treatment depends on the amount of solution injected, and in many cases, you will require more than one treatment session.

Following the injections your legs you may be asked to wear a compression stocking to help heal the veins. This is normally done for 1-2 weeks after treatment.

The treatment is rarely painful; however, some people experience a mild to moderate burning sensation immediately after the injection, but this usually only lasts a few seconds.

Following injection, the thread veins will often appear red for a few days and will then become darker and more obvious than pre-treatment before slowly fading over a few weeks or months.

There is no requirement to follow a specific exercise after thread vein injection.

Are there any side effects or complications from sclerotherapy?

While most patients experience no problems after injection of thread veins, there are some minor side effects reported. The commonest is slight swelling, redness, or bruising which occurs as a reaction to the injection. This occurs immediately after the injections but usually subsides over a few days.

Figure 6a – The same patch of spider veins pre-injection

Figure 6b – The area a few minutes after injection showing the inflammatory reaction associated with successful treatment.

Sometimes clotted blood gets trapped in the veins leaving a dark mark that may take several

months to fade. It is frequently possible to speed up the disappearance of marks like these by removing the trapped blood from the vein with a syringe and needle when the blood softens 4-6 weeks after injections.

Occasionally a small dark area of pigmentation resembling a freckle may remain, or the vein may be replaced with a brownish stain in the line of the vein. This normally fades completely but takes months rather than weeks to fully resolve.

Allergic reactions to the chemical used to carry out the injections can occur but are extremely rare. Very rarely the solution can leak out of the vein and cause ulceration of skin at the injection site that can lead to scarring, but every precaution is taken to prevent this from happening.

How good is micro-sclerotherapy treatment?

Whilst sclerotherapy is very good at treating spider veins, it is important to understand that the leg will look worse before it heals, and the veins disappear.

Although the treated veins should not recur, new thread veins can appear after treatment, and you will have been warned that not every visible vein will disappear following injection. 

This treatment has no effect on the development of varicose veins of the leg. Further thread veins can however be dealt with in the future if required, and many patients elect to have top up treatments every few years.