Spider veins on the legs

Thread veins on the legs: Spider veins, telangiectasias and venous disease

Fine, red or bluish networks of veins in the skin are called thread veins or telangiectasias (veins <1 mm) and reticular veins (1-3 mm). They are very common. In the German Bonn Vein Study (3,072 adults aged 18-79), about 6 in 10 adults had telangiectasias or reticular veins, roughly as often in women as in men, and they are often the first clinical sign of chronic venous disease [1]. The figure is German and dates from the early 2000s.

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What are thread veins?

Thread veins are small, dilated veins close to the skin's surface. Contrary to what the name might suggest, these veins are not broken or bleeding - they are simply enlarged and visible through the skin. On the calves and thighs, they typically appear in clusters or networks and can resemble "spider veins".

In the CEAP classification system, thread veins are class C1 - the earliest clinical stage of venous disease [2].

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Why do they occur?

They develop due to a combination of:

• Hereditary predisposition. A family history is common, and the proportion varies between series [3]
• Hormonal factors - a high oestrogen level is linked to more distensible veins and visible varicose veins, shown in post-menopausal women [4]. In the clinic we see it more often in women, and some notice more broken veins during pregnancy.
• Increased venous pressure from valve dysfunction in the larger, deeper veins
• Sedentary or standing work
• Being overweight
• UV exposure (on the thighs and face)
• Age - the prevalence of more advanced venous disease increases with age

In a Brazilian cross-sectional study of 269 limbs in women with thread veins only (telangiectasias, CEAP C1), underlying reflux in the great or small saphenous vein was found in 46%, most often in the great saphenous vein [5].

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When is it "just cosmetic" - and when is it more?

On their own, thread veins are usually a cosmetic concern and harmless. However, they can be a window to underlying venous disease. Be aware of the following:

• Visible, winding veins on the thigh or calf (varicose veins, C2)
• Swelling around the ankles at the end of the day (C3) - see swollen legs and ankles
• Heavy, tired legs
• Cramps in the calf at night
• Itching or a burning sensation around the dilated veins
• Brownish discolouration or eczema (C4) - a sign of advanced venous hypertension

If you have these symptoms, a Doppler ultrasound should be performed before any cosmetic treatment - otherwise, there is a high risk of rapid recurrence [6].

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Assessment

• Clinical examination in a standing position (this provides the full picture - not lying down)
• Doppler ultrasound if there are accompanying symptoms or visible varicose veins
• Assessment of reflux in the v. saphena magna, v. saphena parva and perforator veins [6]

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Treatment

1. Underlying reflux is assessed first Most thread veins (C1) have no reflux requiring treatment, and are then treated directly; treating reflux is not routine for all thread veins. If a Doppler ultrasound shows reflux in a trunk vein, treating that reflux forms part of the overall assessment, because thread veins otherwise recur more often. Endovenous laser treatment (EVLT) is one of the options: in a Danish randomised trial about 7 per cent of laser-treated trunk veins had recanalised at 5 years, while some patients developed new visible varicose veins within the same period [7].

2. Sclerotherapy (injection treatment) Injection of a liquid or foam agent (polidocanol, sodium tetradecyl sulfate) into the small veins. This is the first-choice treatment for telangiectasias and reticular veins:

• Sclerotherapy works better than no treatment, but the certainty of the evidence is limited and most people need more than one session
• The best evidence supports liquid sclerotherapy for veins <1 mm [8]

3. Surface Laser (transcutaneous laser) Typically used for very fine veins (<0.5 mm) or in areas where injections are difficult - e.g., on the ankles or face. It is often used in combination with sclerotherapy.

4. Conservative measures

• Graduated compression stockings for venous symptoms [9]
• Sun protection, weight management, exercise
• Avoiding prolonged static positions (sitting or standing)

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What is there no evidence for?

• Creams containing horse chestnut, vitamin K or troxerutin have no documented effect on thread veins [10]
• "Natural" dietary supplements do not prevent recurrence if underlying reflux is not treated

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Treatment at Kirurgen.dk

We provide assessment with Doppler ultrasound and treat underlying varicose veins with endovenous laser treatment (EVLT) after a GP referral. Questions about referral, cover and price are clarified with the clinic or your GP before treatment; see contact. Read also about varices (varicose veins) and heavy, tired legs.

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References

1. Rabe E, et al. Bonn Vein Study by the German Society of Phlebology: prevalence and risk factors of chronic venous disorders. Phlebologie 2003;32:1-14.
2. Eklöf B, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg 2004;40(6):1248-52.
3. Cornu-Thénard A, et al. Importance of the familial factor in varicose disease. J Dermatol Surg Oncol 1994;20(5):318-26.
4. Ciardullo AV, et al. High endogenous estradiol is associated with increased venous distensibility and clinical evidence of varicose veins in menopausal women. J Vasc Surg 2000;32(3):544-9.
5. Engelhorn CA, et al. Patterns of saphenous reflux in women with telangiectasias and reticular veins. J Vasc Surg 2007;46(5):964-70.
6. Gloviczki P, Lawrence PF, Wasan SM, et al. The 2022 SVS/AVF/AVLS clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex scanning and treatment of superficial truncal reflux. J Vasc Surg Venous Lymphat Disord 2023;11(2):231-261.e6. DOI: 10.1016/j.jvsv.2022.09.004. PubMed
7. Rasmussen LH, et al. Randomized clinical trial comparing endovenous laser ablation, radiofrequency ablation, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Br J Surg 2011;98(8):1079-87. PubMed (1-year results). Five-year follow-up: Lawaetz M, Serup J, Lawaetz B, et al. Comparison of endovenous ablation techniques, foam sclerotherapy and surgical stripping for great saphenous varicose veins. Extended 5-year follow-up of a RCT. Int Angiol 2017;36(3):281-8. PubMed
8. Rabe E, et al. European guidelines for sclerotherapy in chronic venous disorders. Phlebology 2014;29(6):338-54.
9. Lim CS, Davies AH. Graduated compression stockings. CMAJ 2014;186(10):E391-8.
10. Martinez-Zapata MJ, et al. Phlebotonics for venous insufficiency. Cochrane Database Syst Rev 2020;11:CD003229.