Compression in the Treatment of Leg Telangiectasia: A Preliminary Report MITCHEL P. GOLDMAN, M.D. DENIS BEAUDOING, M.D. WAYNE MARLEY, M.D. LUIS LOPEZ, M.D. ANTON BUTIE, M.D.
PHLEBOLOGY
Abstract. The use of postsclerotherapy compression was evaluated in 37 women with bilaterally symmetrical telangiectatic leg veins. Compressed vessels tended to achieve a greater clinical resolution when located on the distal leg and/or when greater than 0.5 mm in diameter. Postsclerotherapy hyperpigmentation fell from 40.5% to 28.5% with the use of compression. In addition, ankle and calf edema were lessened if a graduated compression stocking was worn immediately after sclerotherapy. J Dermatol Surg Oncol 1990; 16:322-325.
INTRODUCTION Leg telangiectasias are common in women between the ages of 20 and 50. However, they often become aggravated during pregnancy and/or in women who have taken birth control pills.’ Despite their small size, they are frequently sympt~matic.’-~ The
Presented in part a t the 15th Annual Clinical and Scientific Meeting of the American Society for Dermatologic Surgery, Monterey, California, April 16, 1987. This study was supported in part through a grant by Medi USA, Arlington Hts., Illinois. Mitchel P. Goldman, M.D., is Clinical Instructor of Medicine Dermatology, Department of Medicine, Division of Dermatology, University of California, San Diego, California. Denis Beaudoing, M.D., Wayne Marley, M.D., Luis Lopez, M.D., and Anton Butie, M.D., are from the North American Society of Phlebology Multicenter Cooperative Group and are in private practice. Address reprint requests to Mitchel P. Goldman, M.D., 850 Prospect Street, Suite 2, La Jolla, CA 92037.
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most common reason for requesting treatment, however, is for cosmetic improvement. Treatment therefore should be relatively free of any adverse sequelae. Sclerotherapy remains the treatment of choice for these blood vessels.’ Unfortunately, injection sclerotherapy of leg telangiectasias is not totally free of undesirable side effects. The three most common adverse sequelae include postsclerosis pigmentation,’ temporary ankle edema, and telangiectatic matting.3 Goldman and Bennett’ believe that the majority of adverse sequelae can be minimized through proper selection of the sclerosing agent and its concentration combined with meticulous injection technique. Goldmad has presented theoretical considerations and a rationale for the use of compression in sclerotherapy to optimize treatment results. In summary, although postsclerosis compression is now a standard of practice in the treatment of varicose veins, its use in the treatment of smaller abnormal leg veins and spider veins has never been evaluated. This paired comparison study was performed to determine the benefits of immediate postinjection compression of leg telangiectasias.
METHODS Thirty-seven women with bilaterally symmetrical, near-identical, superficial leg telangiectasias of the Duffy type l3(nonmatting, measuring between 0.25 and 1.0 mm in diameter) not associated with larger vessels completed the study. After appropriate informed consent, the vessel diameters were measured with a peak scale light loop with accuracy J Dermatol Sirrg Oncol 16:4 April 2990
GOLDMAN ET AL.
to 0.05 mm. Notation was made as to the location of the vessels. The treatment area was photographed with 1:l magnification utilizing Kodachrome 25ASA film with multiple bracketed exposures. The sclerosant type, quantity, and concentration was left to the discretion of the individual investigator who injected study vessels on both legs in an identical manner. Sclerosing solutions utilized were: Polidocanol (Laboratoiries Pharmaceutiques Dexo, S/t, Nanterre, France) 0.25%-0.75% (14 patients); Sclerodex (Laboratoire Ondee Ltee, Montreal, Canada) (7 patients); Scleremo (Laboratoiries E. Bouteille, Limoges, France) (chromate glycerin 1.11%) (8 patients); sodium tetradecyl sulfate 0.15-0.25% (8 patients). Sclerosing solution volumes for each area treated ranged from 0.5 to 2.0 ml. Identical quantities of sclerosing solution were given to both the compression and noncompression leg. Immediately following injection, cotton balls fixed with paper tape were applied to the injection sites of the noncompression leg. The patient was instructed to remove the dressing in 2 hours. The injection sites of the alternate (compression) leg received an identical cotton ball and paper tape dressing followed by the immediate application of an appropriately sized graduated compression stocking. All stockings had a compression grading of 30-40 mm Hg (American Weco, Medi USA, Arlington Hts., IL). Two hours after injection, the patients removed the cotton ball dressings on both sides while lying prone and reapplied the stocking to the compression leg. The compression stocking was then worn continuously for the next 72 hours. Patients were instructed to walk for 10-15 minutes immediately following the procedure and maintain normal daytime and nighttime activities, including at least a 1-hour walk per day for 1 week. Hot showers or baths and strenuous physical activity (aerobics, weight lifting, and squatting) were to be avoided for 1 week. Photographs were taken pre-injection and at 2 weeks, 2 months, and 4 months postinjection and graded as to visual appearance (Table 1). RESULTS No attempt was made to provide statistical significance in the evaluation of the results from the five investigators in this limited study. This was due to the multiple variables inherent in the study design that allowed each investigator to use his established sclerotherapy technique. Therefore, these results should be viewed as approximations or trends and not as statistical absolutes. Derinntal S l u g Oizcol 16:4 April 1990
TABLE 1 Assessment Scale
I
- 1 = blue thrombus 0 = nochange 1 = slight fade 2 = moderate fade 3 = complete fade Pigmentation (yes or no) Telangiectatic matting (yes or no) Ankle edema (yes or no)
Patient characteristics are summarized in Table 2. The most significant pretreatment finding was that approximately two-thirds of patients complained of leg vein aches after prolonged standing. It should be realized that some of these women had both varicose and telangiectatic leg veins. Only the separate telangiectasia (those not in direct communication with varicosities) were treated in this study. The effectiveness of postsclerosis compression varied with the location of telangiectasia on the leg (Table 3). Compression tended to achieve a greater clinical resolution of the vessels located distally on the leg. This was most marked in the ankle and calf regions. Unfortunately, these groups comprised the smallest number of vessels treated. In the thigh, compression appeared to provide little advantage over noncompression. Effectiveness of treatment in relation to vessel diameter was also evaluated independent of location (Table 4). Little difference in vessel resolution was noted between compressed and noncompressed vessels
PHLEBOLOGY
Abstract. The use of postsclerotherapy compression was evaluated in 37 women with bilaterally symmetrical telangiectatic leg veins. Compressed vessels tended to achieve a greater clinical resolution when located on the distal leg and/or when greater than 0.5 mm in diameter. Postsclerotherapy hyperpigmentation fell from 40.5% to 28.5% with the use of compression. In addition, ankle and calf edema were lessened if a graduated compression stocking was worn immediately after sclerotherapy. J Dermatol Surg Oncol 1990; 16:322-325.
INTRODUCTION Leg telangiectasias are common in women between the ages of 20 and 50. However, they often become aggravated during pregnancy and/or in women who have taken birth control pills.’ Despite their small size, they are frequently sympt~matic.’-~ The
Presented in part a t the 15th Annual Clinical and Scientific Meeting of the American Society for Dermatologic Surgery, Monterey, California, April 16, 1987. This study was supported in part through a grant by Medi USA, Arlington Hts., Illinois. Mitchel P. Goldman, M.D., is Clinical Instructor of Medicine Dermatology, Department of Medicine, Division of Dermatology, University of California, San Diego, California. Denis Beaudoing, M.D., Wayne Marley, M.D., Luis Lopez, M.D., and Anton Butie, M.D., are from the North American Society of Phlebology Multicenter Cooperative Group and are in private practice. Address reprint requests to Mitchel P. Goldman, M.D., 850 Prospect Street, Suite 2, La Jolla, CA 92037.
322
most common reason for requesting treatment, however, is for cosmetic improvement. Treatment therefore should be relatively free of any adverse sequelae. Sclerotherapy remains the treatment of choice for these blood vessels.’ Unfortunately, injection sclerotherapy of leg telangiectasias is not totally free of undesirable side effects. The three most common adverse sequelae include postsclerosis pigmentation,’ temporary ankle edema, and telangiectatic matting.3 Goldman and Bennett’ believe that the majority of adverse sequelae can be minimized through proper selection of the sclerosing agent and its concentration combined with meticulous injection technique. Goldmad has presented theoretical considerations and a rationale for the use of compression in sclerotherapy to optimize treatment results. In summary, although postsclerosis compression is now a standard of practice in the treatment of varicose veins, its use in the treatment of smaller abnormal leg veins and spider veins has never been evaluated. This paired comparison study was performed to determine the benefits of immediate postinjection compression of leg telangiectasias.
METHODS Thirty-seven women with bilaterally symmetrical, near-identical, superficial leg telangiectasias of the Duffy type l3(nonmatting, measuring between 0.25 and 1.0 mm in diameter) not associated with larger vessels completed the study. After appropriate informed consent, the vessel diameters were measured with a peak scale light loop with accuracy J Dermatol Sirrg Oncol 16:4 April 2990
GOLDMAN ET AL.
to 0.05 mm. Notation was made as to the location of the vessels. The treatment area was photographed with 1:l magnification utilizing Kodachrome 25ASA film with multiple bracketed exposures. The sclerosant type, quantity, and concentration was left to the discretion of the individual investigator who injected study vessels on both legs in an identical manner. Sclerosing solutions utilized were: Polidocanol (Laboratoiries Pharmaceutiques Dexo, S/t, Nanterre, France) 0.25%-0.75% (14 patients); Sclerodex (Laboratoire Ondee Ltee, Montreal, Canada) (7 patients); Scleremo (Laboratoiries E. Bouteille, Limoges, France) (chromate glycerin 1.11%) (8 patients); sodium tetradecyl sulfate 0.15-0.25% (8 patients). Sclerosing solution volumes for each area treated ranged from 0.5 to 2.0 ml. Identical quantities of sclerosing solution were given to both the compression and noncompression leg. Immediately following injection, cotton balls fixed with paper tape were applied to the injection sites of the noncompression leg. The patient was instructed to remove the dressing in 2 hours. The injection sites of the alternate (compression) leg received an identical cotton ball and paper tape dressing followed by the immediate application of an appropriately sized graduated compression stocking. All stockings had a compression grading of 30-40 mm Hg (American Weco, Medi USA, Arlington Hts., IL). Two hours after injection, the patients removed the cotton ball dressings on both sides while lying prone and reapplied the stocking to the compression leg. The compression stocking was then worn continuously for the next 72 hours. Patients were instructed to walk for 10-15 minutes immediately following the procedure and maintain normal daytime and nighttime activities, including at least a 1-hour walk per day for 1 week. Hot showers or baths and strenuous physical activity (aerobics, weight lifting, and squatting) were to be avoided for 1 week. Photographs were taken pre-injection and at 2 weeks, 2 months, and 4 months postinjection and graded as to visual appearance (Table 1). RESULTS No attempt was made to provide statistical significance in the evaluation of the results from the five investigators in this limited study. This was due to the multiple variables inherent in the study design that allowed each investigator to use his established sclerotherapy technique. Therefore, these results should be viewed as approximations or trends and not as statistical absolutes. Derinntal S l u g Oizcol 16:4 April 1990
TABLE 1 Assessment Scale
I
- 1 = blue thrombus 0 = nochange 1 = slight fade 2 = moderate fade 3 = complete fade Pigmentation (yes or no) Telangiectatic matting (yes or no) Ankle edema (yes or no)
Patient characteristics are summarized in Table 2. The most significant pretreatment finding was that approximately two-thirds of patients complained of leg vein aches after prolonged standing. It should be realized that some of these women had both varicose and telangiectatic leg veins. Only the separate telangiectasia (those not in direct communication with varicosities) were treated in this study. The effectiveness of postsclerosis compression varied with the location of telangiectasia on the leg (Table 3). Compression tended to achieve a greater clinical resolution of the vessels located distally on the leg. This was most marked in the ankle and calf regions. Unfortunately, these groups comprised the smallest number of vessels treated. In the thigh, compression appeared to provide little advantage over noncompression. Effectiveness of treatment in relation to vessel diameter was also evaluated independent of location (Table 4). Little difference in vessel resolution was noted between compressed and noncompressed vessels
