Original Article

Phlebology
2015, Vol. 30(2S) 46–52
! The Author(s) 2015
Management of reticular veins and Reprints and permissions:
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telangiectases DOI: 10.1177/0268355515592770
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Philip Coleridge Smith

Abstract
Aim: To review the literature related to the management of reticular varices and telangiectases of the lower limbs to
provide guidance on the treatment of these veins.
Findings: Very few randomised clinical trials are available in this field. A European Guideline has been published on the
treatment of reticular varices and telangiectases, which is largely based on the opinion of experts. Older accounts
written by individual phlebologists contain extensive advice from their own practice, which is valuable in identifying
effective methods of sclerotherapy. All accounts indicate that a history should be taken combined with a clinical and
ultrasound examination to establish the full extent of the venous disease. Sclerotherapy is commenced by injecting the
larger veins first of all, usually the reticular varices. Later in the same session or in subsequent sessions, telangiectases can
be treated by direct injection. Following treatment, the application of class 2 compression stockings for a period of up to
three weeks is beneficial but not used universally by all phlebologists. Further sessions can follow at intervals of 2–8
weeks in which small residual veins are treated. Resistant veins can be managed by ultrasound-guided injection of
underlying perforating veins and varices. Other treatments including RF diathermy and laser ablation of telangiectases
have very limited efficacy in this condition.
Conclusions: Sclerotherapy, when used with the correct technique, is the most effective method for the management
of reticular varices and telangiectases.

Keywords
Varicose vein, reticular vein, telangiectases, ultrasound imaging, sclerotherapy

Introduction Ruckley et al.2 found this type of vein in about half

Varicose veins are a common problem in westernised
countries, affecting up to 25% of the adult population,
reticular veins and telangiectases occur more fre-
quently. The CEAP Classification of venous disease
varicose veins of CEAP clinical class 1 is defined as
follows:1
Reticular vein
Dilated bluish sub-dermal vein, usually 1 mm to less
than 3 mm in diameter, usually tortuous, excludes
normal visible veins in persons with thin, transparent
skin. Synonyms include blue veins, subdermal varices
and venulectasies.
of those subjects studied in the Edinburgh Vein Study.
These authors noted a positive correlation between the
presence of superficial venous incompetence and the
presence of telangiectases. The highest frequency of
symptoms (heaviness, swelling, aching and cramps)
was present in patients with both telangiectasia and
varicose veins. The authors found no evidence that tel-
angiectasia per se were entirely responsible for leg
symptoms.
The need for treatment depends on the severity of
the condition and none may be required for the major-
ity of telangiectases or reticular varices, unless cosmetic
improvement is desired.

British Vein Institute, Buckinghamshire, UK

Telangiectasia
Corresponding author:
Confluence of dilated intradermal venules less than Philip Coleridge Smith, British Vein Institute, 24-28 The Broadway,
1 mm in calibre. Synonyms include spider veins, Buckinghamshire HP7 0HP, UK.
hyphen webs and thread veins. Email: p.coleridgesmith@adsum-healthcare.co.uk

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Coleridge Smith
Management of reticular veins and
telangiectases
The history of the treatment of this type of vein com-
menced in the mid-20th century. The sclerosant sodium
tetradecyl sulphate (STS) became widely used in the
1950s after its introduction in 1946 by Reiner.3
Tretbar4 first reported the injection of a 1% solution
into spider angiomata. He noted excellent results in vir-
tually all 144 patients treated. He also noted an
unspecified number of episodes of epidermal necrosis
without significant sequelae and a 30% incidence of
post-sclerosis pigmentation, which resolved within a
few months. Shields and Jansen5 were the first to
describe sclerotherapy of telangiectases with STS in
the dermatological literature. They injected STS (1%)
in 105 patients and reported only one episode of necro-
sis in more than 600 treatments in vessels less than
5 mm in diameter. There were no systemic reactions,
and the majority of post-sclerosis skin pigmentation
resolved in 3–4 months. However, as more experience
with its use in the treatment of leg telangiectases
occurred, even further dilutions (0.1–0.3%) were rec-
ommended, both to achieve clinical efficacy and to
limit adverse sequelae.
Thibault6 has reported on his 2-year experience with
STS used to treat varicose veins and telangiectases. He
evaluated 2665 patients in a 2-year prospective study
and found excellent results with minimal adverse seque-
lae. Using minimally effective sclerosing concentra-
tions, he found a 0.15% incidence of significant or
severe pigmentation that was identical to the rate
found with another sclerosing solution, polidocanol.
Four patients (0.15%) developed uncomplicated ana-
phylactoid reactions with two patients (0.07%)
developing urticaria.
Assessment of patients with telangiec-
tases and reticular varices
In patients with venous disease, history taking, clinical
examination and duplex ultrasound examination are
recommended by many authors. The European
Guidelines for Sclerotherapy in chronic venous dis-
orders recommends this strategy in most patients.7 In
some patients, these guidelines indicate that continuous
wave Doppler examination may be sufficient to evalu-
ate the venous system. As demonstrated in the
Edinburgh Vein Study, truncal saphenous incompe-
tence commonly accompanies telangiectases and
although a causal relationship has not been clearly
demonstrated, most phlebologists consider that
addressing the incompetent saphenous veins and vari-
ces in such cases is prerequisite to successful manage-
ment of the telangiectases. Where previous varicose
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47
veins surgery or ablation has been undertaken, residual
sections of saphenous vein or major tributaries may
remain and contribute to the development of telangiec-
tases. These should be identified and can be managed
by ultrasound guided sclerotherapy during the treat-
ment of the telangiectases.
Technique of sclerotherapy
The use of compression sclerotherapy in the treatment
of varicose veins depends not only on the solution
which is used but also on the technique used to treat
the varicose veins. The method of managing the patient
is very important in achieving a good outcome. A
modern method of sclerotherapy has been described
by Thibault, including details of the treatment room
that he uses, suitable sclerosants and continued man-
agement of patients following treatment.8 A well-lit
treatment room with diffuse overhead lighting rather
than an operating light is recommended. The patient
lies supine whilst the sclerotherapist moves around
the lower limbs.
Thibault (and other authors) emphasise the import-
ance of treating saphenous veins, tributaries, reticular
varices and telangiectases in order to obtain a satisfac-
tory outcome. The sequence of treatment starts with the
largest (saphenous) veins, continuing with smaller tri-
butaries and reticular varices and concluding with tel-
angiectases. He specifically notes that injection of
telangiectases alone will not lead to a satisfactory out-
come, since the reticular varices are a conduit of high
venous pressure that will lead to early recurrence of
telangiectases, if these are not treated adequately. His
technique is systematic sclerotherapy of reticular vari-
ces in one limb at a time, possibly accompanied by
sclerotherapy of associated telangiectases. Injection of
the reticular varices alone may lead to disappearance of
many telangiectases. Residual veins can be treated in
subsequent sessions. Thibault recommends the treat-
ment of all the reticular veins in one limb in one session,
within the limitations of the maximum permissible
amount of sclerosant that may be injected.
The anatomy of the medial and lateral limb plexuses
of reticular veins and associated telangiectases has been
described by Weiss and Weiss.9 These authors also
emphasise that in the treatment of telangiectases,
sclerotherapy is directed primarily at the associated
reticular veins proceeding from the largest to the smal-
lest veins. The authors note that direct injection of tel-
angiectases is required when no further reticular veins
can be found.
The European Guidelines record that needles with a
size of 27–32 g are used for the treatment of reticular
varices and telangiectases.7 These are usually combined
with small syringes with a capacity of 1–3 mL.
48
Numerous different methods of injection are advised,
though most practitioners hold the skin and underlying
veins with one hand to immobilise them and manipu-
late the syringe with the other. In the UK, a method of
using a sclerotherapy injection set in which a 30 g
needle is attached to the syringe using a flexible tube,
in a similar design to a butterfly needle, is also used
(Figure 1).
The European Guidelines recommend a maximum
volume of sclerosant injected in any one vein of up to
0.2 mL when treating telangiectases and up to 0.5 mL
when treating reticular varices. The maximum total
amount of sclerosant which may be injected in any
one session depends upon the sclerosant. Different
manufacturers recommend different maximum doses
of the sclerosant (see below) (Figure 2).
Figure 1. Sclerotherapy set with 30 g needle (STD
Pharmaceuticals Ltd, Hereford, UK).
Figure 2. (a) Cannulation of reticular vein with successful aspiration of blood to check that the needle is in the vein. (b) The same
vein as Figure 2(a) immediately following injection of sclerosant.
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Phlebology 30(2S)
Sclerosant drugs used in the management
of telangiectases and reticular varices
The two most widely used sclerosant drugs for the man-
agement of varicose veins are polidocanol
(AethoxysklerolÕ , Kreussler, Germany; ScleroveinÕ ,
Resinag, Switzerland) and STS (FibroveinÕ , STD
Pharmaceuticals Ltd, UK). In most European coun-
tries, at least one of these drugs is licensed for the treat-
ment of varicose veins. Both are also licensed in the
United States. These drugs are detergents and achieve
their effects by the lysis of cell membranes. Both have
long provenance in the management of varicose veins
and are of low toxicity.
Fibrovein is licensed in the UK at a concentration of
0.2% for the management of reticular varices and tel-
angiectases. The maximum volume recommended to be
injected by the Summary of Product Characteristics in
one session is 10 mL. Polidocanol is unlicensed in the
UK but fairly widely used despite this. The Summary of
Product Characteristics indicates a maximum dose of
2 mg/kg per day. The European Guidelines calculate
that this would allow up to 28 mL of 0.5% polidocanol
solution in a 70 kg patient in one day. The manufac-
turers recommend that treatment is avoided during
pregnancy, lactation and in patients taking oestrogen
treatment.
A double-blind comparison between polidocanol
and STS has been undertaken by Goldman.10 He
found that, when used at the recommended concentra-
tions both drugs had similar efficacy in clearing telan-
giectases and reticular varices with a similar incidence
of adverse events.
In France, the osmotic sclerosant chromated glycer-
ine (Scleromo) is used. This is unlicensed in most other
countries and not widely used. Its mode of action is by
desiccating the endothelium of the veins in which it is
injected. The concentration of glycerine in this solution
Coleridge Smith 49

is 70%, making it more painful to inject than the deter-
gent sclerosants. Its effect also tends to be milder with
efficacy mainly confined to telangiectases.
Management following sclerotherapy
The methods used following sclerotherapy of varicose
veins vary considerably from country to country.
Following treatment of saphenous varices, it has been
claimed that compression eliminates thrombophlebitic
reaction and substitutes a ‘sclerophlebitis’ with the pro-
duction of firm fibrous cord.11 Fegan had a similar
opinion when he devised his injection – compression
technique and considered that uninterrupted compres-
sion of the limb for six weeks was required to avoid
phlebitis.12 However, a Cochrane review was unable
to conclude that any particular technique of injection
or compression led to an advantage in outcome.13 The
quality of data reviewed in this study was limited and
therefore the true situation has probably not yet been
fully evaluated.
The management of the limb following sclerotherapy
of telangiectases and reticular varices is also subject to a
range of practices. The European Guidelines say that
compression may be applied following sclerotherapy
using stockings or bandages.
Kern has investigated the efficacy of compression in
managing the outcome of sclerotherapy for telangiec-
tases and reticular varices.14 In a randomised clinical
trial, he compared the outcome following three weeks
compression with class 2 medical compression stock-
ings, worn during the day, to a control group who
wore no compression. He found that photographic
assessment at 52 days following treatment showed a
superior result in the compression group compared to
the control subjects. Nevertheless, some phlebologists
do not advise the use of compression. This is often
influenced by the climate, since compression stockings
are poorly tolerated in hot climates. In the UK, most
sclerotherapists recommend the application of com-
pression using bandages or stockings following treat-
ment although no recent detailed survey has been
conducted. Following thermal ablation or foam sclero-
therapy for saphenous varices most surgeons in the UK
apply compression to the treated limb,15 whereas in
France only about one-third of doctors apply compres-
sion following sclerotherapy.16
The authors already mentioned above as well as the
European Guidelines on sclerotherapy recommend a
series of treatments. Intervals between treatments vary
from 2 to 8 weeks but this is not based on any detailed
research. Thibault mentions that the reason for re-
treatment is that following sclerotherapy of reticular
varices as well as telangiectases, some veins remain
after each treatment and these can be addressed in
future sessions, leading to an improved outcome.6 I
have summarised a simplified strategy for the manage-
ment of reticular varices and telangiectases in Table 1.
Events after sclerotherapy for telangiec-
tases and reticular varices
Immediately following a session of sclerotherapy, an
acute inflammatory reaction is provoked by intraven-
ous injection of sclerosants. This includes a central
swollen region surrounded by a red flare and comprises
Lewis’s Triple Response to any noxious stimulus to the
skin. This is short lived and resolves in 1–2 h after treat-
ment. This reaction is followed by some bruising of the
skin in regions which have been injected, which will
resolve in about 1–2 weeks (Figure 3). After this,
many veins appear dark in colour where thrombus
has occluded the veins. Some reticular veins appear
brown in colour, others become blue-green which dis-
tinguishes them from untreated veins. One problem
that may arise is that the retained thrombus leads to

Table 1. Simplified algorithm for the management of reticular varices and telangiectases.

1. Evaluate the venous system of the lower limbs by clinical examination and ultrasound imaging.
2. Treat incompetent saphenous trunks and tributaries using thermal ablation or foam sclerotherapy.
3. Commence by injecting the reticular varices. Use a maximum volume of 0.5 mL of 0.2% STS liquid per injection until all veins have
been injected. Polidocanol 0.5% can also be used but is unlicensed in the UK.
4. Inject all remaining telangiectases in the treated area with 0.2% STS liquid with a maximum volume of 0.2 mL per injection.
Polidocanol 0.5% can also be used but is unlicensed in the UK.
5. Conclude the session when all veins have been treated or the maximum recommended volume of sclerosant has been reached.
6. At the end of the session apply a class 2 medical compression stocking to the limb (including the thigh) for a period of up to three
weeks.
7. Review after 2–8 weeks and treat residual reticular varices followed by telangiectases. Reapply compression and review after a
further 2–8 weeks. Treat remaining veins as from step 3 above.
8. If telangiectatic matting occurs, check for underlying veins with duplex ultrasound imaging and inject these. Review after 1–3
months and continue treatment from step 3 above.
9. 1–3 months after conclusion of a course of treatment, most or all veins will have been successfully treated and reabsorbed.

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50 Phlebology 30(2S)

Figure 3. (a) Bruising of treated region one week following sclerotherapy. (b) Clearance of veins four weeks after treatment.

pigmentation of the skin. It has been shown that evacu-

ation of the thrombus from occluded veins results in a
reduction in skin pigmentation.17
In my own practice, I find it useful to review patients
at this stage, two weeks following the previous session,
at which time it is clear which veins have been success-
fully occluded by thrombus and which require further
treatment. Excess thrombus can be removed by aspir-
ating with a 25 g needle, and residual reticular varices
and telangiectases can be injected. The occluded reticu-
lar veins will usually resolve in 1–3 months depending
on their size. Occasional patients experience protracted
skin pigmentation, especially those of Mediterranean
origin. Unfortunately, there appears to be no treatment
or manoeuvre which will resolve this problem more
rapidly – but all skin pigmentation following sclerother-
apy will fade and usually resolve completely after an
extended period. Phlebologists assign the responsibility
for skin pigmentation to excessive strength of sclero- Figure 4 An example of embolia cutis medicamentosa follow-
sant or the injection of an excessive volume. ing sclerotherapy of reticular veins.
However, some patients are especially susceptible to
this problem.
Rare complications include:
Complications of sclerotherapy 1. Embolia cutis medicamentosa (inadvertent intra-
The European Guidelines provide a long list of compli- arterial injection of a skin arteriole, Figure 4)
cations of foam and liquid sclerotherapy. Most of these 2. Skin rashes due to allergy
are very infrequent and have been reported mainly 3. Anaphylaxis
following foam sclerotherapy, such as visual disturb-
ance, neurological events and DVT. The most
common adverse events after liquid sclerotherapy I have already discussed some aspects of manage-
include: ment of the more common complications. Minor skin
necrosis needs simple dressings and perhaps antibiotic
1. Thrombophlebitis treatment if clinical evidence of infection arises.
2. Skin pigmentation Telangiectatic matting may arise in a region of previous
3. Residual veins treatment which has been subjected to vigorous treat-
4. Minor skin necrosis ment. These veins will resolve without intervention over

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Coleridge Smith
a period of about three months. However, if the
affected region still contains untreated veins, it is sug-
gestive of resistance to treatment in the patient con-
cerned. Use of larger volumes of sclerosant or greater
concentration will simply worsen the matting. A strat-
egy has been suggested by Schuller-Petrovic which is
commonly used amongst phlebologists.18 Using a
high-frequency ultrasound transducer, search is made
for underlying veins and perforators. These can be very
small, typically 0.5–2 mm in diameter. Ultrasound-
guided sclerotherapy with liquid can then be used to
ablate these veins. Any incompetent saphenous trunks
or tributaries which are also found should be treated as
well. Several sessions of this type of treatment may be
required if resistant telangiectases are widespread. This
ultrasound guided strategy is effective at clearing telan-
giectases where sclerotherapy guided by eye is not.
Inadvertent intra-arterial injection (embolia cutis
medicamentosa, Nicolau syndrome) is a rare complica-
tion of sclerotherapy. This most frequently arises fol-
lowing visually guided sclerotherapy since ultrasound
imaging usually identifies the arteries so that injection
of these is avoided. The result is a very painful region
around the point of injection with a dark purple or blue
discolouration. Current recommendations include high
dose steroids combined with anticoagulation but some
tissue damage may arise despite these measures.
Severe allergic reactions (anaphylaxis) require imme-
diate treatment with adrenaline given via intravenous
or intramuscular routes, in accordance with nationally
published guidelines for management. In some coun-
tries, the use of steroids is also advised. Intravenous
fluids and inhaled oxygen are also recommended. The
detailed management of this medical emergency is
beyond the scope of this article.
In the longer term, patients who develop reticular
veins and telangiectases continue to develop more
veins even in the absence of any clear precipitating
factor such as the development of saphenous vein
incompetence. In most patients, sclerotherapy as
described above continues to be effective. Occasional
further treatments will maintain a satisfactory outcome
and cosmetic appearance, which is the main aim of
most treatments of this type.
Alternative treatments for telangiectases
Lasers are sometimes recommended in the management
of telangiectases of the lower limb. In contrast to
sclerotherapy, the only veins which this can ablate are
the most superficial and smallest veins which are usu-
ally pink in colour. Reticular veins are too large to be
destroyed by a light beam passed through the skin.
Dover has reviewed this subject and concluded that
lasers are much less effective than sclerotherapy in the
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51
management of reticular varices and telangiectases of
the lower limb.19
I am aware that radiofrequency diathermy (elec-
trolysis) is sometimes used in the management of telan-
giectases of the leg. However, I can find no published
data on which such practice is based.
Conclusions
Sclerotherapy for the management of varicose veins has
long been established as a means of treating reticular
varices and telangiectases in the lower limb. Limited
scientific literature is available to guide practice in
this field. However, European Guidelines have been
published and provide general guidance in this field.
More detailed advice is offered from the accounts of
clinical series published by a number of authors. In
general, clinical and ultrasound examination is required
to identify all components of the venous disease present
in the limbs of patients with reticular varices and tel-
angiectases. Any saphenous varices are treated first.
Sclerotherapy for small veins commences with reticular
varices and proceeds to telangiectases, usually over a
number of sessions. Compression of the limb following
treatment using a class 2 medical compression stocking
has been shown to improve the outcome. Resistant tel-
angiectases can be treated with the help of ultrasound
guided injection of underlying perforating and tribu-
tary veins. Complications of treatment are few and
most are readily managed by simple means.
Conflict of interest
None declared.
Funding
This research received no specific grant from any funding
agency in the public, commercial or not-for-profit sectors.
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