Sclerotherapy: Old wine in new bottle

Dermatologists are successfully using sclerotherapy, a longstanding treatment for spider veins, to improve the appearance of aging hands. Rajshri Srinivasan reviews the options available

The development of sclerotherapy (derived from Greek word meaning "hardening") has been a long and chequered one. The earliest successful use of sclerotherapy / prolotherapy has been recorded as early as 500 B.C. when Roman soldiers with shoulder joint dislocations were treated with hot branding irons to help fuse the torn ligaments in the shoulder joint. Hippocrates described vein sclerotherapy around 400 B.C. using "slender instruments of iron" to treat varicose veins causing vein ulcers.

Much later, in the year 1682, D Zollikofer a Swiss scientist injected an acid into a vein to induce thrombus formation. Nearly two hundred years later, in the 1800s sporadic work was done on this novel treatment procedure. Scientists reported success in treating varicose veins by injecting perchlorate of iron. In 1854, 16 cases of varicose veins by injecting iodine and tannin into the veins. However, due to high rates of side-effects with the drugs used at the time, sclerotherapy had been practically abandoned by 1894.

It is in the past 150 years that research on sclerotherapy techniques in varicose veins have evolved. In the early 20th century, carbolic acid and perchlorate of mercury were tried and whilst these showed some effect in obliterating varicose veins, side-effects also caused them to be abandoned. Prof. Sicard and other French doctors developed the use of sodium carbonate and then sodium salicylate during and after the First World War. Quinine was also used with some effect during the early 20th century. In 1926, a group of physicians met with great success using injection therapy to treat hernias and hemorrhoids.

Further work on improving the technique and development of safer more effective sclerosants continued through the 1940s and 1950s. Of particular importance was the development of Sodium Tetradecyl Sulfate (STS) in 1946, a product still widely used to this day. Earl Gedney, D.O., a well-known Orthopaedist, used sclerotherapy in the 1940s and 1950s. Also, in 1950, George Stuart Hackett, M.D., wrote a book on injection therapy. His work is still used today in training physicians.

George Fegan in the 1960s reported treating over 13,000 patients with sclerotherapy, significantly advancing the technique by focusing on fibrosis of the vein rather than thrombosis, concentrating on controlling significant points of reflux, and emphasizing the importance of compression of the treated leg.

The next major development in the evolution of sclerotherapy was the advent of duplex ultrasonography in the 1980s and its incorporation into the practice of sclerotherapy later that decade.

Techniques

Sclerotherapy, is a method by which an irritating chemical called a sclerosing agent is injected into the tissues. Also known as prolotherapy (proliferative therapy), ligament reconstruction therapy, and fibro-osseous injection therapy it is a recognized orthopaedic procedure that stimulates body's natural healing processes to strengthen joints weakened by trauma or over-use injury. Joints, ligaments or tendon attachments are stretched, torn, or fragmented, become hypermobile and painful. In such cases, when traditional methods like surgery and drugs fail, sclerotherapy can relieve this pain permanently.

Sclerotherapy, with its unique ability to directly address the cause of the instability, can repair the weakened sites and produce new fibrous tissues, resulting in permanent stabilization of the joint.

With a precise injection of a mild irritant solution directly on the site of the torn or stretched ligament or tendon, sclerotherapy creates a mild, controlled injury that stimulates the body's natural healing mechanisms to lay down new tissue on the weakened area. The mild inflammatory response that is created by the injection encourages growth of new ligament or tendon fibres, resulting in a tightening of the weakened structure. Additional treatments repeat this process, allowing a gradual build-up of tissue to restore the original strength to the area.

Sclerotherapy can also be used to treat varicose veins, spider veins, hemorrhoids, and other similar abnormalities. In these conditions, sclerotherapy creates a mild inflammatory response causing them to contract so that they become smaller or even vanish.

In varicose veins, the chemical causes the vein to become inflamed, which leads to the formation of fibrous tissue and closing of the lumen, or central channel of the vein. Sclerotherapy scars the vein away, meaning that over a series of several months the vein disappears on the surface. The solution irritates the lining of the vein, causing the blood to thicken and block the vessel. It then breaks down into scar tissue, which is further broken down by the body over a period of a few weeks. Any resulting scar tissue is either completely invisible or barely noticeable, and the vein no longer exists.

Sclerotherapy treatment is recommended by dermatologists as a strictly cosmetic procedure. Dermatologists are successfully using sclerotherapy - a longstanding treatment for spider veins - to improve the appearance of aging hands.

As dermatologists continue to treat facial aging with much success, patients are increasingly aware of other visible areas of the body - particularly the hands, neck, and the upper part of a woman's chest - that need to be addressed to avoid looking years older than their face. Hands reveal one's age second only in frequency to the face and, as in facial skin aging, discoloration of the skin, fine lines, and loss of volume can make the hands look older. Sclerotherapy can help minimize prominent hand veins and significantly improve appearance of the hands.

This procedure is usually conducted on an outpatient basis, allowing the individual receiving sclerotherapy to return home immediately following the procedure. Following sclerotherapy treatment, the treated part is wrapped bandages and/or anti-embolism stockings, applying external pressure.

Success depends on factors which include the history of damage to the patient, the patient's overall health and ability to heal, and any underlying nutritional deficiencies that would impede the healing process.

The compression after sclerotherapy treatment seals the vein walls together, allowing the body to break down and absorb the vein. Sclerotherapy treatment is considered complete when the vein is no longer visible. Sometimes multiple sclerotherapy treatments are required to achieve optimal results, usually with four to six weeks between one sclerotherapy treatment and the next, allowing time for the body to respond.

The sclerotherapy injections contain anaesthetic agents and natural substances which stimulate the healing response. There are numerous substances, and each treating physician tailors the selection of substance according to the patient's need.

Any pain involving an injection will vary according to the structure to be treated, the choice of solution, and the skill of the physician administering the injection. The treatment may result in mild swelling and stiffness. The mild discomfort passes fairly rapidly and can be reduced with pain relievers. Non-Steroidal Anti-inflammatory drugs, such as aspirin and ibuprofen, should not be used for pain relief because their action suppresses the desired inflammatory process produced by the injection.

It is used for children and young adults with vascular or lymphatic malformations. There are several different solutions that can be used, depending on the size of the blood vessel and other factors. The problem with injecting liquid sclerotherapy in any vein other than thread veins is that the liquid not only interacts with the vein wall but also interacts with the blood. This means that as soon as liquid sclerotherapy is injected into a vein, the blood reacts with it and forms a clot.

This has two effects. The first is that if the blood is not flushed away by the liquid sclerosant, the clot will remain in the vein making the sclerotherapy less effective on the veins wall. The second is that the clot of blood can then break down with time causing a raised lump which often stains brown on the skin surface. These stains are called "haemosiderin".

Physicians who administer this form of therapy are trained by the American College of Osteopathic Pain Management & Sclerotherapy. Postgraduate training is a prerequisite before treating any patient with a medical orthopaedic problem, vein problem, or other condition which might benefit from sclerotherapy.

Treatment innovations

The latest types of sclerotherapy used are: foam sclerotherapy and ultrasound sclerotherapy.

Foam sclerotherapy: Foam sclerotherapy is a technique that involves injecting "foamed sclerosant drugs" within a blood vessel using a syringe. The sclerosant drugs - Sodium Tetradecyl Sulfate (STS) or polidocanol - are mixed with air or a physiological gas (carbon dioxide) in a syringe or by using mechanical pumps. This increases the surface area of the drug. The foam sclerosant drug is more efficacious than the liquid one in causing sclerosis for it does not mix with the blood in the vessel and in fact displaces it, thus avoiding dilution of the drug and causing maximal sclerosant action. It is therefore useful for longer and larger veins. Experts in foam sclerotherapy have created "tooth paste" like thick foam for their injections, which has revolutionized the non-surgical treatment of varicose veins and venous malformations, including Klippel Trenaunay syndrome (characterized by a triad of port-wine stain, varicose veins, and bony and soft tissue hypertrophy involving an extremity).

To make foam, the liquid sclerotherapy solution is mixed with air using two syringes. This produces foam which has the consistency of shaving foam. This can then be injected directly into the veins. The blood is pushed out of the vein, meaning that the sclerotherapy solution now has a direct action on the vein wall alone. The treatments should be administered every one, two, or three weeks, as determined by your treating physician. Vein treatments are usually scheduled four or more weeks apart.

Foam sclerotherapy offers the following advantages:

1. It makes better contact with the wall of the vein than a liquid sclerosing agent.

2. It allows the use of smaller amounts of chemical

3. Its movement in the vein can be monitored on an ultrasound screen.

4. Sclerosing foam has been shown to have a high success rate with a lower cost, and causes fewer major complications.

Ultrasound sclerotherapy: Ultrasonographic guidance is another latest development in this evolution. In ultrasound-guided sclerotherapy, the underlying vein can be visualized so that the physician can deliver and monitor the injection. Sclerotherapy under ultrasound guidance and using micro foam sclerosants has been shown to be effective in controlling reflux from the sapheno-femoral and sapheno-popliteal junctions. However, some authors believe that sclerotherapy is not suitable for veins with reflux from the greater or lesser saphenous junction, or veins with axial reflux (above the knees).

Advantages of sclerotherapy

• Sclerotherapy is the "gold standard" and is preferred over laser for eliminating large spider veins (telangiectasiae) and smaller varicose leg veins.
• Unlike a laser, the sclerosing solution additionally closes the "feeder veins" under the skin that are causing the spider veins to form, thereby making a recurrence of the spider veins in the treated area less likely.
• Sclerotherapy is better than surgery in terms of treatment success, complication rate and cost at one year
• Sclerotherapy is far more effective in destroying the veins and also the risks of blood clots and brown staining is far less.
• Sclerotherapy is more effective and less costly than laser treatments, and it is a relatively inexpensive procedure that can be used in areas of the body other than the legs - including the hands, breasts, and face.
• Many patients who choose sclerotherapy treatment have severe varicose veins, mainly in their legs. In some of these cases, the sclerotherapy treatment helps prevent new varicose veins from forming, although this is not always the case.

Clinical evaluations

A study by Kanter and Thibault in 1996 reported a 76 percent success rate at 24 months in treating sapheno-femoral junction and great saphenous vein incompetence with STS three percent solution. Padbury and Benveniste found that ultrasound guided sclerotherapy was effective in controlling reflux in the small saphenous vein. Barrett et al. found that micro foam ultrasound guided sclerotherapy was "effective in treating all sizes of varicose veins with high patient satisfaction and improvement in quality of life".

A Cochrane Collaboration review of the medical literature concluded that "The evidence supports the current place of sclerotherapy in modern clinical practice, which is usually limited to treatment of recurrent varicose veins following surgery and thread veins."

Drawbacks

Cosmetically, the chief risk of sclerotherapy is that new spider veins may develop after the procedure. New spider veins are dilated blood vessels that can form when some of the venous blood forms new pathways back to the larger veins. Some patients may develop telangiectatic matting, which is a network of new spider veins that surface around the treated area. Telangiectatic matting usually clears up by itself within three to 12 months after sclerotherapy, but it can also be treated with further sclerosing injections.

Other risks of sclerotherapy include severe inflammation, venous thromboembolism, pain after the procedure lasting several hours or days, allergic reactions to the sclerosing solution or foam, permanent scarring, edema and loss of sensation. Ulceration of the skin and hirsutism has also been observed in some cases.

The possible side effects of sclerotherapy vary with the type of solution injected and may include pain at the injection site, muscle cramps immediately after the injection, skin pigmentation around the treatment area. A history of blood clots is not necessarily a reason to avoid sclerotherapy or vein treatment. Patients should keep in mind that veins may reappear or new veins may form in their place after any spider or varicose vein procedure, including sclerotherapy.

Some conditions and disorders are considered contraindications for sclerotherapy. Pregnant women are advised to postpone sclerotherapy until at least three months after the baby is born, because some spider veins will fade by themselves after delivery. Nursing mothers should postpone sclerotherapy until the baby is weaned because it is not yet known whether the chemicals used in sclerotherapy may affect the mother's milk.

Diabetes, a history of AIDS, hepatitis, syphilis, or other blood borne diseases, heart conditions, high blood pressure, blood clotting disorders, and other disorders of the circulatory system are also contraindication

Cost factors

Discussing various sclerotherapy cost factors is a "must" for patients who are looking into this treatment, since the overall sclerotherapy cost can rise very quickly under certain circumstances. In many cases, insurance will cover the sclerotherapy costs, if it is being conducted for medical reasons, such as to reduce pain.

While the sclerotherapy cost for cosmetic procedures is the same, insurance is generally not available for cosmetic treatments. After sclerotherapy cost is discussed with the doctor, patients should get a written estimate indicating the projected sclerotherapy cost and then check with their insurance company to see if part or all of this sclerotherapy cost will be covered under their policy. The cost of sclerotherapy depends upon several factors like the amount of time a doctor spends treating the veins, whether a doctor or a technician conducted the treatment, the amount of treatment needed, and the extent of vein problems. Patients will pay higher sclerotherapy costs if they need multiple treatments

Overall, patients are extremely pleased with their results and report an improved self-image and overall feeling of well-being that is commonly associated with cosmetic procedures. For patients who want more dramatic outcomes, a multi-pronged approach using other minimally invasive therapies can complement sclerotherapy - such as using laser and light devices to fade skin discoloration or to increase collagen production.