Periocular sclerotherapy requires modifications

Chicago - Traditionally used to treat unwanted veins in the legs and thighs, sclerotherapy can provide an effective tool in other areas as well, according to David Green, M.D., a Bethesda, Md.-based private practitioner and clinical assistant professor of dermatology at Howard University Hospital, Washington, D.C.

"Although sclerotherapy is performed almost exclusively on legs and thighs, it can be used elsewhere just as effectively. However, few dermatologists treat veins other than those on the legs and thighs," Dr. Green says.

"Sclerotherapy is a very effective technique, and varicose and spider veins are exquisitely sensitive to this procedure," he tells Dermatology Times.

In spite of that fact, he says most physicians actually limit the use of sclerotherapy to the removal of spider veins and continue to recommend surgical intervention for the removal of varicose veins.

"Vascular surgeons and dermatologists have historically been taught that larger veins require surgical removal and often perpetuate the myth that varicose veins don't respond," Dr. Green says. "However, the vast majority of varicose veins, no matter how large they are, can be treated by sclerotherapy without surgery as long as there is no significant reflux from junctional or perforating vein incompetence."

In keeping with his philosophy, Dr. Green uses sclerotherapy for unwanted facial veins.

"Very frequently," he says, "people, especially women, develop prominent veins on the eyelids or around the eyes - periocular veins - which they find unsightly and want removed. Dermatologists have attempted to remove these veins with a variety of lasers. Unfortunately, the success rate with laser is quite low and laser procedures are rather uncomfortable."

Ophthalmologists and oculoplastic surgeons have tried surgically excising or ligating such veins.

"But again, that procedure is usually disappointing," he maintains. "However, sclerotherapy, when done properly, is almost 100 percent successful at removing these prominent periocular veins."

He also treats prominent veins on the back of the hands, feet, ankles, chest and breast.

What is it?

"Sclerotherapy involves injection of what is referred to as a solution of a 'sclerosing' agent," he says, "but it's more properly designated a 'denaturing' agent. The 'denaturing' agent used most often is sodium tetradecyl sulfate.

"The chemical solution, essentially, denatures the constituents of the vein wall, which is primarily composed of collagen. If we denature the full thickness of the wall, the body can't repair the vein, and the vein will ultimately be absorbed. And the vein lumen will disappear as well."

This biologic effect of sclerotherapy is the same no matter what site on the body a vein is treated, he asserts.

"Differences exist, though, at different sites. For example, veins around the eyes, where the vessels are subjected to lower gravitational hydrostatic pressure, paradoxically require a much higher concentration of solution than one would otherwise expect compared to the same size vein on the leg or thigh. If one uses the same concentration for veins around the eyes that one expects to use for veins on the legs and thighs, usually the result is treatment failure," he says.

Periocular treatment

When treating prominent periocular veins, Dr. Green says, "it's often necessary to use anywhere from 0.5 percent to 1.0 percent sodium tetradecyl sulfate. For similarly sized veins on the legs and thighs - and we're not referring to large, protruding varicose veins - I use anywhere from 0.20 percent to 0.33 percent sodium tetradecyl sulfate. Having treated many patients on the face with a lower concentration, I discovered the veins don't go away. Only by trial and error have I found it necessary to use these higher concentrations in order for results to be reproducible."