Version May 2024
INTRODUCTION — Injection sclerotherapy is a minimally invasive percutaneous technique using chemical irritants to close unwanted superficial veins [1,2]. Sclerotherapy is primarily used in the treatment of telangiectasias, reticular veins, and small nonaxial varicose veins (<6 mm), which may or may not be symptomatic, and even in the absence of symptoms can be a source of significant distress to some patients.
Sclerotherapy techniques for the treatment of telangiectasias, reticular veins, and small, nonaxial varicose veins (<6 mm) are reviewed. The use of sclerosing agents to treat superficial venous insufficiency of the saphenous veins or perforator veins is reviewed separately. (See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency".)
Alternative approaches to treatment of telangiectasia, reticular veins, and small, nonaxial varicose veins (<6 mm) are also reviewed separately. (See "Laser and light therapy of lower extremity telangiectasias, reticular veins, and small varicose veins" and "Approach to treating symptomatic superficial venous insufficiency", section on 'Ambulatory phlebectomy'.)
VENOUS ANATOMY — The superficial veins of the lower extremity are classified as axial or nonaxial. The axial veins include the great, small, and accessory saphenous veins (figure 1A-B).
Nonaxial superficial veins, including the intersaphenous veins, lateral veins, and other nonaxial veins, have variable anatomy. (See "Classification of lower extremity chronic venous disorders", section on 'Superficial venous system (As)'.)
●Telangiectasias are a confluence of dilated intradermal venules <1 mm in diameter (picture 1A-B).
●Reticular veins are dilated bluish subdermal veins 1 to 3 mm in diameter (picture 1A-B). They are usually tortuous.
●Varicose veins are subcutaneous dilated veins 3 mm or greater in size (picture 2A-B). Smaller varicose veins (<6 mm) typically involve saphenous vein tributaries or nonsaphenous superficial leg veins.
The deep veins of the lower extremity (figure 2) are contained within the muscle compartments bounded by the muscle fascia. (See "Classification of lower extremity chronic venous disorders", section on 'Deep venous system (Ad)'.)
Perforator veins are those veins that traverse the muscular fascia to connect superficial veins with the deep veins. These are located anteriorly, posteriorly, laterally, and medially in both the thigh and calf. (See "Classification of lower extremity chronic venous disorders" and "Classification of lower extremity chronic venous disorders", section on 'Perforator veins (Ap)'.)
INDICATIONS — Superficial telangiectasias, reticular veins, and varicose veins are the visible signs of chronic venous disease and can occur in the presence or absence of either symptoms or an underlying functional venous disorder (ie, venous reflux) [2]. Candidates for sclerotherapy are patients with persistent symptoms and signs of chronic venous disease refractory to medical management. (See "Overview of lower extremity chronic venous disease", section on 'Approach by clinical severity' and "Approach to treating symptomatic superficial venous insufficiency", section on 'Candidates for venous intervention'.)
While telangiectasias, reticular veins, and small, nonaxial varicose veins (<6 mm) may be symptomatic, most are asymptomatic, but patients often find the cosmetic appearance of their veins distressing. Sclerotherapy can generally be performed following physical examination in those who are asymptomatic without further diagnostic studies, as these patients are less likely to have underlying venous reflux compared with symptomatic patients [2,3]. (See 'Patient counseling' below.)
Patients with stigmata of recent venous bleeding or recurrent bleeding from telangiectasias, reticular veins, and small, nonaxial varicose veins (<6 mm) may benefit from sclerotherapy of that vein site [4,5]. After bleeding is controlled by elevation and direct pressure over the bleeding varicose vein, duplex examination is performed [6]. Additional treatments may be warranted to manage superficial venous reflux. However, sclerotherapy of veins that have bled is often successful even in the presence of venous reflux [4]. (See "Overview of lower extremity chronic venous disease", section on 'Bleeding'.)
Contraindications — Sclerotherapy should not be performed in patients who have signs of acute venous thrombosis (superficial, deep). While other ablation techniques have been investigated for managing superficial venous thrombosis, the results of these studies cannot be generalized to sclerotherapy.
We agree with venous guidelines that pregnant individuals should defer treatment until after delivery [7,8]. Sclerosing agents are not approved for use in the US during pregnancy. Moreover, telangiectasis, reticular veins, and small, nonaxial varicose veins (<6 mm) will often regress in the months following delivery and not require any treatment at all [9,10]. There are some studies that suggest that sclerosing solutions do cross the placenta, although their specific effects are not well characterized. While available studies have not identified adverse maternal or fetal outcomes [8,11], sclerotherapy of telangiectasias, reticular veins, and small, nonaxial varicose veins is considered an elective cosmetic procedure, and any risk would not be justified.
Diabetes and evidence of peripheral artery disease are relative contraindications due to an increased risk for wound complications, but this depends upon the nature and extent of sclerotherapy being considered and the presence of ischemia.
A history of migraine headache and patent foramen ovale are relative contraindications to foam sclerotherapy due to a risk for microembolism. The risk appears to be limited to physician-compounded foam using room air due to the nitrogen content in room air. Physician-compounded foam made with carbon dioxide or a mixture of carbon dioxide/oxygen does not necessarily carry this contraindication. Microembolism has not been reported with proprietary microfoam formulations. (See 'Formulations' below and "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Sclerotherapy' and "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Visual and other neurologic disturbances'.)
Alternatives — Vein clearance rates and overall patient satisfaction generally favors sclerotherapy over cutaneous laser for reticular veins or larger varicose veins [12,13]. Once reticular or larger varicose veins have been cleared, clearance rates for telangiectasias are comparable. Also, due to the risk of longstanding hypopigmentation from laser and light treatments, liquid sclerotherapy is a more appropriate choice for patients with Fitzpatrick skin types IV, V, and VI (table 1). Laser/light treatments are recommended for patients who have failed sclerotherapy, those with veins too small to access (<0.3 mm; smaller than 30-gauge needle) or poor outcome, patients with postsclerotherapy matting, needle-phobic patients, and patients who are allergic to sclerosant agents. Laser/light treatment is also preferred for vessels located at or below the ankle regions, which are more prone to ulceration with sclerotherapy due to increased risk of intra-arterial injection [14]. (See "Laser and light therapy of lower extremity telangiectasias, reticular veins, and small varicose veins".)
PATIENT COUNSELING — The decision to offer sclerotherapy depends upon symptoms, response to conservative therapy, extent of lower extremity disease, and likelihood of providing a durable benefit, either with respect to appearance or improvement in symptoms. For all patients, it is important to address patient expectations, potential adverse effects, potential failure of treatment, and the complications of treatment. Sclerotherapy of telangiectasias, reticular veins, and small, nonaxial varicose veins is generally considered a cosmetic treatment and in the United States is typically not covered by insurance, though occasionally it will be reimbursed if a vein has bled.
Patients treated for cosmetic purposes need to be carefully counseled prior to treatment. Patients must understand that the results of cosmetic sclerotherapy are unpredictable in spite of expert technique, and some patients with favorable conditions (Fitzpatrick skin type I and II, ideal injections) (table 1) may still have results they deem unsatisfactory. Patients should be informed that veins will lighten and become less noticeable but may not completely disappear, that hyperpigmentation is a relatively common complication, and that multiple treatments are typically required to achieve the desired effect. Thus, it is important for the clinician to document veins photographically prior to each treatment and to review these photographs with the patient periodically. (See 'Timing of vein treatments' below.)
SCLEROTHERAPY AGENTS AND FORMULATIONS — Sclerotherapy agents cause endothelial damage by their actions as either osmotic or detergent agents (table 2). Osmotic agents achieve their effect by dehydrating endothelial cells through osmosis. Detergents are surface-active agents that damage the endothelium by interfering with cell membrane lipids [15]. In vitro, the detergent agents also exhibit procoagulant activity at lower concentrations and anticoagulant activity in higher concentrations [16].
Agents — The most common sclerotherapy agents used in the treatment of lower extremity chronic venous disease are polidocanol, sodium tetradecyl sulfate, hypertonic saline, and glycerin (table 2). In the United States, only polidocanol and sodium tetradecyl sulfate are approved for this indication. Systematic reviews of randomized trials of sclerotherapy for telangiectasias, reticular veins, or small, nonaxial varicose veins have found no high-quality evidence to support the use of one sclerosant over another in the short-term success of injection sclerotherapy [17-19]. Agent selection is according to availability and clinician experience. However, there are some agent-specific advantages and differences in adverse reactions, which are detailed below [17].
Polidocanol — Polidocanol, also known as aethoxysklerol, is a detergent. Polidocanol is available in a liquid or foam formulation. In one systematic review that compared various sclerotherapy agents, polidocanol was no more painful than placebo for the treatment of telangiectasias [19]. This is a significant advantage of this agent. The maximum dosage of polidocanol depends on the weight of the patient. Polidocanol concentrations of 0.5 and 1% were recommended for spider veins and reticular veins (<3 mm), respectively, when polidocanol was initially approved for use in the US in 2010. Depending on the diameter of the treated vein, dilutions can be used, with concentrations lower than 1% used for narrower veins (table 2).
Sodium tetradecyl sulfate — Sodium tetradecyl sulfate is a commonly studied sclerosant agent [18]. Dilutions between 0.1 and 3.0% are used depending on the diameter of the vein treated, with lower concentrations used for narrower veins (table 2). Overall efficacy sodium tetradecyl sulfate appears to be similar to polidocanol [15,20]. However, some have suggested that sodium tetradecyl sulfate may cause more local adverse reactions. As an example, in a systematic review limited to treatment of telangiectasias, sodium tetradecyl sulfate at a concentration of 1% was more likely to cause complications compared with polidocanol at 0.5% [19]. In a later systematic review evaluating sclerotherapy for varicose veins, various agents, concentrations, and techniques produced similar results [21]. The maximum recommended dosage is 10 mL of a 3% solution in the US and Canada; the volume used varies worldwide depending on formulation.
Hypertonic saline — Hypertonic saline is an osmotic agent sometimes still used for lower extremity sclerotherapy, although not approved for use in the US. Dilutions between 11.7 and 23.4% are used depending on the diameter of the treated vein, with lower concentrations used for narrower veins (table 2). Hypertonic saline is frequently mixed with local anesthetic to reduce the pain associated with injection (eg, 20% saline plus 2% lidocaine).
An agent that is a mixture of hypertonic saline (10%) and dextrose (25%), a relatively weak sclerosing agent, is also available (ie, Sclerodex); however, it has not been approved for use in the United States.
Glycerin — Chromated glycerin is a potent osmotic sclerosant that is less commonly used for lower extremity sclerotherapy. Dilutions between 25 and 72% are used depending on the diameter of the vein treated, with lower concentrations used for narrower veins (table 2). The maximum recommended amount per session is 10 mL [22]. While very popular worldwide, it is not commercially available in the US.
Formulations — Venous sclerotherapy agents can be formulated as a liquid or foam (ie, polidocanol endovenous microfoam or physician-compounded foam). For ablation of telangiectasis, reticular veins, or small, nonaxial varicose veins (<6 mm) that can admit a 27- to 30-gauge needle, a liquid formulation is selected rather than foam to avoid the potential complications associated with foam. Liquid sclerotherapy can also be used to treat residual or recurrent veins following endovenous ablation or surgery, and perforator veins.
In principle, foam sclerotherapy can be used on all vein calibers, and vein clearance is probably similar [17,23-29]; however, a minority of practitioners would use a foam preparation for treating telangiectasias or reticular veins because it would subject the patient to potential risks (eg, matting, microembolism related to room air physician-compounded microfoam) without any additional benefit [26,29-31]. Therefore, foam sclerotherapy is predominantly applied to the treatment of reflux of the superficial axial veins (great, small, accessory saphenous) and reflux of perforator veins [32]. (See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Sclerotherapy' and "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Foam sclerotherapy technique'.)
TREATMENT APPROACH
Timing of vein treatments — Asymptomatic telangiectasias, reticular veins, and small, nonaxial varicose veins (<6 mm) are frequently not associated with venous hypertension and can be treated as deemed necessary. Unless the veins have bled, their treatment is generally considered cosmetic. Several sessions are typically needed to fully treat and obliterate treated veins, with a minimum of six weeks between sessions.
When visibly dilated superficial veins are associated with typical symptoms (ie, pain, aching, swelling, fatigue), a venous duplex ultrasound is important to exclude axial venous insufficiency prior to treating the dilated superficial nonaxial veins. Sclerotherapy of nonaxial veins is not likely to be as effective, either initially or long-term, in the presence of persistent venous hypertension. To manage the associated nonaxial veins, clinicians may choose to handle residual veins at the same time as the superficial venous ablation or stage the procedures with phlebectomy or sclerotherapy at some interval following the ablation. (See "Approach to treating symptomatic superficial venous insufficiency", section on 'Treatment timing'.)
TECHNIQUES AND FOLLOW-UP — For patients with associated axial venous reflux, the axial vein is ablated prior to managing the nonaxial veins. (See 'Sclerotherapy agents and formulations' above and 'Timing of vein treatments' above.)
Telangiectasias, reticular veins, and small varicosities (<6 mm) are treated using a liquid sclerosant, which is effective at eliminating the treated veins with high rates of patient satisfaction [18,33,34]. However, there is no consensus on specific aspects of sclerotherapy technique, including the type of sclerosing agent, use of local anesthetic, use or type of local compression pad, and use or duration of compression dressing (bandage or elastic). Typical sessions last from 15 to 60 minutes.
Clearance of treated telangiectasias, reticular veins, and small, nonaxial varicose veins can be expected but often requires serial treatment sessions. Recurrence of telangiectasias and reticular veins in the same area from recanalization is uncommon and most often is attributable to inadequate technique [33,35]. The development of new telangiectasias and reticular veins over time is more typical following sclerotherapy. Telangiectatic matting can occur but is typically due to a feeding reticular vein that has not been fully treated or eradicated. (See 'Adverse reactions' below.)
Injection method — In general, the sclerosant liquid is mixed into a syringe at the appropriate concentration for the vein to be treated (table 2).
The syringe is attached to a 27- or 30-gauge needle (sometimes a 33-gauge for the smallest telangiectasias), which is angled to assist its introduction into the vessel. The patient is placed in Trendelenburg position during injection to empty the vein of blood, which increases the contact time between the vein wall and the sclerosant. Following the application of alcohol to clean the area, the needle is introduced into the vein and with loss of resistance, which identifies the intraluminal needle placement, the sclerosant is then injected.
To treat telangiectasias, reticular veins, or small, nonaxial varicose veins (<6 mm), the amount of liquid sclerosant that is injected depends on the size of the vein being treated (table 2). Increasing concentrations and larger amounts are used for larger veins. When larger underlying reticular veins are identified, these are treated prior to addressing more superficial telangiectasias. A vein light (fiberoptic illuminator) is helpful for identifying reticular veins. Once the sclerosant has been injected, the needle is withdrawn and local compression and massage is used to keep blood out of the lumen of the vessel and to help disperse the sclerosant. Local compression pads (eg, mole foam, sorbo pads, dental bumpers, cotton balls) are placed and fixed with tape to maintain compression while moving on to the next vein. When vessels are treated sequentially from distal (ankle) to proximal (thigh) on the limb and from larger to smaller veins, over 90 percent of vessels can be successfully treated.
The procedure is terminated when the maximum volume of sclerosant has been injected (table 2) or all the veins of interest have been treated. A light dressing is placed at the puncture sites, and graduated compression stockings or bandages (eg, Coban, Elastocrepe, Ace) are applied. (See 'Compression therapy' below.)
Providing no adverse reactions have occurred, the patient can be discharged. The patient is counseled to ambulate normally and may return to work.
Compression therapy — Following injection sclerotherapy for telangiectasias, reticular veins, and small, nonaxial varicose veins (<6 mm), we advise our patients to wear compression stockings continuously for 48 hours after treatment, after which time any local compression pads or bandages can be removed and compression stockings worn during the day (off at night and to bathe) for the next two weeks. Other regimens are used successfully, and this aspect of care remains a matter of debate.
A systematic review of older trials of injection sclerotherapy for varying sizes of varicose veins identified no differences in sclerotherapy success related to bandaging compared with elastic compression [18]. Bandaging >72 hours did not provide advantages over short-term bandaging for cosmetic appearance or the incidence of superficial phlebitis or recurrent varicose veins. Short-term bandaging was also tolerated better than longer-term bandaging.
The benefit of compression stockings following sclerotherapy for telangiectasias and reticular veins has been documented in some, but not all [36], studies. Three trials suggested improved cosmetic outcomes with three weeks of compression stockings rather than shorter or no compression stockings following sclerotherapy of telangiectasias [37-39]. In one of these studies, a total of 40 patients with telangiectasias and/or reticular veins were treated with sclerotherapy [38]. Ten control patients did not receive compression stockings, while 30 patients in three groups of 10 received compression stockings for three days, one week, or three weeks. There was a correlation between the degree of improvement and length of time compression stockings were applied at 6, 12, and 24 weeks. Patients treated with compression stockings for three days or one week had significantly more improvement than control patients, while patients treated for three weeks had the most improvement.
Instructions — Exercise is avoided for two weeks and treated areas should not be exposed to the sun during this period. Alternatively, sunscreen with a high sun protection factor (SPF ≥30) may be applied to the treated areas.
The patient should contact the clinician immediately if increasing pain is experienced or if any ulcerations appear at the injection sites. Repeat injections, which are frequently needed to manage varicosities within a specific region, are not performed for at least six weeks.
If a foam preparation has been used, the patient is also instructed to call their clinician if they experience unusual cough or visual, sensory, or motor disturbances.
ADVERSE REACTIONS — The type of adverse reaction following injection sclerotherapy generally depends upon the sclerosing agent used (table 2) [18].
Common local adverse reactions to sclerosing agents include pain, ulceration, urticaria, hyperpigmentation, and telangiectatic matting (table 2) [40]. A mild inflammatory response is expected after sclerotherapy, and some patients may have urticaria at the site of injection. A more intense superficial thrombophlebitis with erythema, warmth, and pain can extend to veins neighboring the injection site. Most local reactions are transient and resolve within months following the procedure [41].
Allergic reactions to sclerosing agents occur in <1 percent of patients, but anaphylaxis is rare [42-44]. In one large prospective multicenter registry of over 12,000 sclerotherapy sessions, anaphylaxis was not reported [45]. If a local or systematic reaction manifests, the sclerotherapy session should be terminated and standard protocols followed. (See "Anaphylaxis: Emergency treatment".)
Vasovagal reactions to the injections have also been reported.
Visual and other neurologic disturbances can occur, more typically following use of foam preparations. (See "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Sclerotherapy' and "Nonthermal, nontumescent ablation techniques for the treatment of lower extremity superficial venous insufficiency", section on 'Visual and other neurologic disturbances'.)
Minor pain — Pain is common at the sclerotherapy injection site. Significant pain during injection may be an indication that the sclerosing agent has extravasated into the tissue around the vein. Polidocanol is associated with the least amount of pain upon injection [18], whereas hypertonic saline and glycerin are the most painful, especially when used without lidocaine [46].
Ulceration — Ulcers may occur when the sclerosing agent extravasates from the vein into the subcutaneous tissue. The reported incidence is 1 to 5 percent of patients treated (picture 3A). Care must be taken to ensure that the needle is intraluminal before the sclerosant is injected. (See 'Techniques and follow-up' above.)
When ulcers occur, they are usually small and most often heal with local care in four to six weeks. However, they may result in scarring. Polidocanol is rarely associated with skin ulceration or necrosis because it is nontoxic to tissues [15,41].
Skin breakdown may also occur in response to excessive pressure from tape or compression garments [40].
Larger areas of skin necrosis may be related to retrograde flow of the sclerosant through an unexpected cutaneous arteriovenous malformation or the inadvertent injection of a small arteriole. This type of skin necrosis is rare and is independent of the type of sclerosant used.
Thrombus — Thrombus forms within the vessel when blood contacts the sclerosing agent. The resulting mild inflammatory reaction is a source of post-treatment pain and is more common with treatment of reticular veins and small varicose veins compared with telangiectasias.
Microthrombectomy, which removes clot, significantly reduces postsclerotherapy pain and inflammation and in one multicenter randomized trial reduced hyperpigmentation in vessels smaller than one millimeter [47]. Microthrombectomy is typically performed at one to three weeks following treatment by making very small stab incisions (18- to 22-gauge needle or No. 65 Beaver blade) along the length of the thrombosed vein with aseptic technique. Thrombus is extruded by rolling a cotton-tipped applicator along the course of the vein, and the area is cleansed and dressed using sterile bandages. Topical local anesthesia is not usually necessary but may be helpful in some individuals.
Telangiectatic matting — Telangiectatic matting consists of multiple, fine, dilated vessels in the area of the injection site (picture 4). It is relatively common, occurring in 15 to 24 percent of patients, and usually resolves within 3 to 12 months [48]. Sodium tetradecyl sulfate is associated with a lower incidence of telangiectatic matting [18].
In one retrospective review of 2120 patients, significantly more patients in the matting group were overweight, taking female hormones (estrogen, progesterone) during sclerotherapy treatment, and had both a family history and a longer duration of abnormal veins compared with the non-matting group [48].
If a reticular vein can be identified feeding the area of matting, repeat sclerotherapy can be attempted; otherwise, the area can be treated with cutaneous laser once inflammation has subsided [49]. (See "Laser and light therapy of lower extremity telangiectasias, reticular veins, and small varicose veins".)
Hyperpigmentation — Hyperpigmentation occurs in up to 30 percent of patients following sclerotherapy (picture 3A-B). It is caused by deposition of hemosiderin in the skin as a result of extravasation of red blood cells. It usually becomes noticeable within one month following sclerotherapy and resolves spontaneously in 80 percent of patients within two years [50]. It occurs more commonly with treatment of veins greater than one millimeter in diameter and in patients with darker hair and Fitzpatrick skin types III through VI (table 1) [40].
Hyperpigmentation is less frequent with sodium tetradecyl sulfate, and this agent is also associated with less bruising [18]. Treatment of telangiectasias with lower concentrations of polidocanol (0.5% versus 1%) reduced the incidence of hyperpigmentation with this agent [44].
It is important for patients who experience hyperpigmentation to avoid sun exposure to the treated areas. Laser/light therapy may be tried in the treatment of postsclerotherapy hyperpigmentation, but the results are unpredictable, and occasionally pigmentation is worsened [49,51]. The treatment of cutaneous hyperpigmentation is discussed elsewhere. (See "Laser and light therapy for cutaneous hyperpigmentation".)
A technique called radiofrequency thermocoagulation may improve the cosmetic appearance after sclerotherapy. In a trial that randomized 111 patients to sclerotherapy alone or sclerotherapy followed by thermocoagulation, there was significantly less trapped blood and less hyperpigmentation in the group treated with thermocoagulation [52].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic venous disorders".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Vein ablation (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Candidates for injection sclerotherapy – Injection sclerotherapy uses chemical irritants, which cause endothelial damage, to close unwanted superficial veins and is the treatment of choice for telangiectasias, reticular veins, and small, nonaxial, varicose veins (<6 mm) large enough to admit a 27- or 30-gauge needle. Candidates are patients with persistent symptoms and signs of chronic venous disease refractory to medical management or those with recent (or recurrent) bleeding. (See 'Indications' above and "Overview of lower extremity chronic venous disease", section on 'Approach by clinical severity'.)
●Contraindications – Injection sclerotherapy is contraindicated in the presence of acute venous thrombosis (superficial or deep). Patients with risk factors for poor wound healing (eg, diabetes, peripheral artery disease) represent a relative contraindication. We also defer any treatment during pregnancy, since telangiectasias, reticular veins, and small, nonaxial varicose veins (<6cmm) often regress after delivery. (See 'Contraindications' above.)
●Evaluation – Diagnostic studies are generally not necessary for asymptomatic individuals with telangiectasias, reticular veins, and small, nonaxial varicose veins (<6 mm), which are often not associated with underlying venous reflux. For symptomatic patients, we suggest duplex ultrasound to identify superficial axial venous reflux, which alters treatment timing. (See 'Treatment approach' above.)
●Managing associated axial venous reflux – When axial venous reflux is identified in conjunction with telangiectasias, reticular veins, or small, nonaxial varicose veins (<6 mm), the axial vein is ablated prior to managing the nonaxial veins. (See 'Timing of vein treatments' above.)
●Formulations – Agent selection (table 2) is according to availability and clinician experience. For ablation of telangiectasis, reticular veins, or small, nonaxial varicose veins (<6 mm diameter) that can admit a 27- to 30-gauge needle, we suggest liquid sclerotherapy rather than foam sclerotherapy (Grade 2C). Foam sclerosing agents subject the patient to potential risks without any added benefit. (See 'Sclerotherapy agents and formulations' above.)
●Techniques – There is no consensus on specific aspects of sclerotherapy technique. Following injection sclerotherapy, compression pads/bandages are left in place at the sclerotherapy sites. We advise our patients to wear compression stockings continuously for 48 hours to reduce pain and bruising, after which time the compression pads/bandages are removed. Subsequently, compression stockings are worn during the day for at least two weeks. (See 'Techniques and follow-up' above.)
●Adverse reactions and recurrence – Common adverse reactions include pain or ulceration at the injection site, localized thrombus, telangiectatic matting, and hyperpigmentation, the frequency of which depend upon the agent used (table 2). More severe complications are rare. New telangiectasias and reticular veins commonly develop over time. (See 'Adverse reactions' above.)
●Postprocedure instructions – Following injection sclerotherapy, we advise exercise avoidance for two weeks, and treated areas should not be exposed to the sun. Minor pain is common at the injection sites. The clinician should be contacted immediately for increasing pain or development of ulceration at the injection site. Follow-up treatment may include microthrombectomy to evacuate any accumulated thrombus in the treated veins. (See 'Compression therapy' above and 'Instructions' above and 'Adverse reactions' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Deborah Greenberg, MD, FACP, who contributed to earlier versions of this topic review.
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