LETTERS AND COMMUNICATIONS
care. Interestingly, only 1 of 21 patients (4.8%) reported pain (pain score 5/10) as the reason for discontinuation of BTX-A. Pain is well controlled using ice with pressure during the procedure, and it does not prevent patients from returning for continued management with BTX-A. Instead, insurance exclusion of BTX-A and high costs seem to be the major contributing factors for the cessation of treatment. References 1. Strutton D, Kowalski J, Glaser D, Stang P. U.S. prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004;51:241–8. 2. Lear W, Kessler E, Solish N, Glaser D. An epidemiological study of hyperhidrosis. Dermatol Surg 2007;33:S69–75.
3. Solomon B, Hayman R. Botulinum toxin type a therapy for palmar and digital hyperhidrosis. J Am Acad Dermatol 2000;42:1026–9. 4. Glaser D, Hebert A, Pariser D, Solish N. Palmar and plantar hyperhidrosis: best practice recommendations and special considerations. Cutis 2007;79(Suppl l):18–28.
Alison Kang, BA Erin Burns, MD Dee Anna Glaser, MD Department of Dermatology Saint Louis University School of Medicine St. Louis, Missouri Dr. Dee Anna Glaser is a consultant and investigator for Allergan, Inc. Alison Kang and Dr. Erin Burns have no conflicts of interest.
Primary Varicose Vein of the Upper Limb
Primary varicose veins (VVs) of the upper limb are very rare with only few reports in the last decades. In this article, a case of symptomatic primitive VV of the left upper limb is reported including diagnosis and treatment. This 63-year-old woman presented with a 2-year history of a VV on the left arm progressively increased in caliber and extension (Figure 1A). In the last weeks, the VV was associated with pain and heavy feeling. Symptoms and vein turgidity worsened during the hotter hours of the day and sun exposure. Duplex demonstrated a varicose epifascial vein running obliquely in the superficial hypodermis of the anteromedial face of the arm. This VV connected the basilic with the cephalic veins, which appeared normal in size (Figure 2). Duplex excluded anatomic or hemodynamic abnormalities in the deep and the other superficial veins, at rest and during maneuvers testing for venous thoracic outlet syndrome (vTOS). Occlusive compression of the subclavian and axillary veins and vascular malformations were excluded by dynamic CT venography. No other VV could be observed in other territories. Under local anesthesia, the connection with the basilic vein was isolated and ligated with Vicryl 3-0.
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Then, multiple phlebectomies were performed up to the margin of the deltoid muscle. The proximal end of the VV was ligated. A graduated compression arm sleeve was applied for 10 days. No complications were observed (Figure 1B). Two years later, an excellent functional and cosmetic result was observed with no recurrence.
Figure 1. (A) The left arm at admission. (B) 3D-CT showing the epifascial path of the VV (arm elevated). (C) 3D-CT showing the connection of the VV with the cephalic and basilica veins (arm elevated). (D) The left arm, 10 days after operation.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Discussion VV of the upper limb are in most cases secondary to thrombosis of the axillosubclavian veins or to congenital vascular anomalies. Primary VV are very rare, and the literature has few references regarding their causes, prevalence, and management.1–3 Their rarity explains why they are not mentioned in current treatises on venous diseases.4 Dilation of subcutaneous veins of the dorsum of the hand are not considered pathological and treated only for cosmetic purposes.5 VV limited to one or more fingers have been seldom reported. In this case, treatment of the VVs was necessary because of increasing size and worsening symptoms. Stab avulsion with ligation of the distal and proximal connections of the vein gave immediate pain relief and a good aesthetic result with no complications and recurrences. Sclerotherapy was not performed because of the absence of studies regarding the use of foam in the proximal upper limb. Stripping was not considered even if proposed in the past for VVs of the upper limb.3 The possible cause of varicose changes observed in this case cannot even be hypothesized. The patient denied local trauma or cannulation and symptoms
suggesting previous inflammatory episodes. Duplex and CT excluded thrombosis and vTOS as well as other anatomic and hemodynamic abnormalities. Finally, even if VV are considered because of a genetic defect in venous wall metabolism and morphology, no varicose changes were observed in other parts of her body. References 1. Clark DM, Warren R. Idiopathic varicose veins of the upper extremity. N Engl J Med 1954;250:408–12. 2. Davis RP, Lipsing LJ, Connolly Mark M, Flinn WR. Varicose ulcer of the upper extremity. Surgery 1985;98:616–8. 3. Welch HJ, Villavicencio MD. Primary varicose veins of upper extremity: a report of 3 cases. J Vas Surg 1994;5:839–43. 4. Gloviczki P. Handbook of venous disorders. Hodder Arnold: London, United Kingdom, 2009. 5. Duffy DM, Garcia C, Clark RE. The role of sclerotherapy in abnormal hand varicose hand veins. Plast Reconstr Surg 2000;106: 227–9.
Alberto Caggiati, MD, PhD Department of Anatomy Sapienza University of Rome Rome, Italy The authors have indicated no significant interest with commercial supporters.
41:2:FEBRUARY 2015
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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care. Interestingly, only 1 of 21 patients (4.8%) reported pain (pain score 5/10) as the reason for discontinuation of BTX-A. Pain is well controlled using ice with pressure during the procedure, and it does not prevent patients from returning for continued management with BTX-A. Instead, insurance exclusion of BTX-A and high costs seem to be the major contributing factors for the cessation of treatment. References 1. Strutton D, Kowalski J, Glaser D, Stang P. U.S. prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: results from a national survey. J Am Acad Dermatol 2004;51:241–8. 2. Lear W, Kessler E, Solish N, Glaser D. An epidemiological study of hyperhidrosis. Dermatol Surg 2007;33:S69–75.
3. Solomon B, Hayman R. Botulinum toxin type a therapy for palmar and digital hyperhidrosis. J Am Acad Dermatol 2000;42:1026–9. 4. Glaser D, Hebert A, Pariser D, Solish N. Palmar and plantar hyperhidrosis: best practice recommendations and special considerations. Cutis 2007;79(Suppl l):18–28.
Alison Kang, BA Erin Burns, MD Dee Anna Glaser, MD Department of Dermatology Saint Louis University School of Medicine St. Louis, Missouri Dr. Dee Anna Glaser is a consultant and investigator for Allergan, Inc. Alison Kang and Dr. Erin Burns have no conflicts of interest.
Primary Varicose Vein of the Upper Limb
Primary varicose veins (VVs) of the upper limb are very rare with only few reports in the last decades. In this article, a case of symptomatic primitive VV of the left upper limb is reported including diagnosis and treatment. This 63-year-old woman presented with a 2-year history of a VV on the left arm progressively increased in caliber and extension (Figure 1A). In the last weeks, the VV was associated with pain and heavy feeling. Symptoms and vein turgidity worsened during the hotter hours of the day and sun exposure. Duplex demonstrated a varicose epifascial vein running obliquely in the superficial hypodermis of the anteromedial face of the arm. This VV connected the basilic with the cephalic veins, which appeared normal in size (Figure 2). Duplex excluded anatomic or hemodynamic abnormalities in the deep and the other superficial veins, at rest and during maneuvers testing for venous thoracic outlet syndrome (vTOS). Occlusive compression of the subclavian and axillary veins and vascular malformations were excluded by dynamic CT venography. No other VV could be observed in other territories. Under local anesthesia, the connection with the basilic vein was isolated and ligated with Vicryl 3-0.
298
Then, multiple phlebectomies were performed up to the margin of the deltoid muscle. The proximal end of the VV was ligated. A graduated compression arm sleeve was applied for 10 days. No complications were observed (Figure 1B). Two years later, an excellent functional and cosmetic result was observed with no recurrence.
Figure 1. (A) The left arm at admission. (B) 3D-CT showing the epifascial path of the VV (arm elevated). (C) 3D-CT showing the connection of the VV with the cephalic and basilica veins (arm elevated). (D) The left arm, 10 days after operation.
DERMATOLOGIC SURGERY
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
LETTERS AND COMMUNICATIONS
Discussion VV of the upper limb are in most cases secondary to thrombosis of the axillosubclavian veins or to congenital vascular anomalies. Primary VV are very rare, and the literature has few references regarding their causes, prevalence, and management.1–3 Their rarity explains why they are not mentioned in current treatises on venous diseases.4 Dilation of subcutaneous veins of the dorsum of the hand are not considered pathological and treated only for cosmetic purposes.5 VV limited to one or more fingers have been seldom reported. In this case, treatment of the VVs was necessary because of increasing size and worsening symptoms. Stab avulsion with ligation of the distal and proximal connections of the vein gave immediate pain relief and a good aesthetic result with no complications and recurrences. Sclerotherapy was not performed because of the absence of studies regarding the use of foam in the proximal upper limb. Stripping was not considered even if proposed in the past for VVs of the upper limb.3 The possible cause of varicose changes observed in this case cannot even be hypothesized. The patient denied local trauma or cannulation and symptoms
suggesting previous inflammatory episodes. Duplex and CT excluded thrombosis and vTOS as well as other anatomic and hemodynamic abnormalities. Finally, even if VV are considered because of a genetic defect in venous wall metabolism and morphology, no varicose changes were observed in other parts of her body. References 1. Clark DM, Warren R. Idiopathic varicose veins of the upper extremity. N Engl J Med 1954;250:408–12. 2. Davis RP, Lipsing LJ, Connolly Mark M, Flinn WR. Varicose ulcer of the upper extremity. Surgery 1985;98:616–8. 3. Welch HJ, Villavicencio MD. Primary varicose veins of upper extremity: a report of 3 cases. J Vas Surg 1994;5:839–43. 4. Gloviczki P. Handbook of venous disorders. Hodder Arnold: London, United Kingdom, 2009. 5. Duffy DM, Garcia C, Clark RE. The role of sclerotherapy in abnormal hand varicose hand veins. Plast Reconstr Surg 2000;106: 227–9.
Alberto Caggiati, MD, PhD Department of Anatomy Sapienza University of Rome Rome, Italy The authors have indicated no significant interest with commercial supporters.
41:2:FEBRUARY 2015
© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
299
