Expert Recommends Foam Sclerotherapy for Varicose Veins

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.