Laser and Skin

Spider veins: veins first, then looks

Spider veins are the smallest form of varicose veins: vessels under 1 millimetre wide just beneath the skin, most often on the thighs, behind the knees and around the ankles, and found in about 41% of women over 50. Sclerotherapy or a vascular laser clears most of them in 2 to 4 sessions, but the sensible order starts with a 15 to 30 minute duplex ultrasound of the leg veins, because in a fair share of cases the visible vessels are fed by a leaking valve deeper down, and treating the surface alone means paying twice.

What spider veins are, and what they are not

Spider veins, telangiectasias in the clinic, are dilated vessels less than 1 millimetre across that lie in the upper layer of the skin and show as red, blue or purple lines, often fanning out from a single feeding point. Vein specialists file them under the same heading as varicose veins, as class C1 on the CEAP scale that runs from C0 (no visible veins) to C6 (an open venous ulcer). Reticular veins, the blue-green feeders 1 to 3 millimetres wide that often lie beneath a cluster of spider veins, belong to the same class; anything over 3 millimetres counts as a varicose vein proper.

They are common. The Cochrane review that pooled 35 randomised trials puts leg telangiectasias in 41% of women over 50, and the incidence rises further with age; pregnancy, standing occupations, excess weight and family history all add to the risk. The vessels rarely hurt and on their own they are harmless; some people notice burning or itching over a dense patch, most notice nothing but the look.

What matters is what lies underneath. In a fair share of cases spider veins are the surface sign of a valve that no longer closes in a larger vein, so that blood pools downwards and the pressure looks for an outlet in the smallest vessels under the skin. Treat only the surface and the same patch tends to return within 1 to 2 years, because the pressure from below has not changed. That is why the scan comes before the device.

What the ultrasound has to answer

A duplex ultrasound of the leg veins takes 15 to 30 minutes, needs no preparation and does not hurt. The examiner follows the two long superficial trunk veins, the great saphenous vein along the inside of the leg and the small saphenous vein at the back of the calf, squeezes the calf and watches on screen whether blood runs the wrong way when the pressure is released. A backflow lasting longer than about 0.5 seconds marks a valve that has stopped doing its job; in the deep veins the threshold is 1 second.

The British guideline on varicose veins, NICE CG168, makes duplex ultrasound the standard step before any interventional treatment, and it lists the symptoms that call for referral to a vascular service regardless of how the legs look: aching, heaviness, swelling, itching, discolouration or eczema on the lower leg, hard and painful superficial veins, and any break in the skin below the knee that has not healed within 2 weeks. Purely cosmetic treatment is not funded in most public health systems, so the scan also sorts out who is a patient and who is a customer.

If the scan finds reflux in a trunk vein, that vein is closed first, typically with heat from a laser or radiofrequency catheter under local anaesthetic, an outpatient procedure with success rates around 95% and compression for no more than 7 days afterwards. Only then do the spider veins get their turn. If the trunk veins are competent, the usual finding when spider veins are the only complaint, the surface can be treated with a clear conscience.

Sclerotherapy or laser, the calibre decides

Sclerotherapy works from inside. A fine needle, usually 30 gauge, delivers a sclerosant such as polidocanol at 0.25 to 0.5% or sodium tetradecyl sulphate into the vessel; the lining is irritated, the walls stick together and the body absorbs the closed vein over the following weeks. The method suits everything a needle can enter: reticular veins of 1 to 3 millimetres and the larger spider veins fed by them. A session lasts 15 to 45 minutes and clears one region of the leg at a time.

The vascular laser works from outside. On the legs the standard is the long-pulsed 1064 nanometre Nd:YAG, whose light is absorbed by haemoglobin, heats the vessel and seals it, with a cooled tip to protect the skin; the 532 and 595 nanometre lasers used on facial vessels reach too shallow for the leg. Laser suits vessels too fine for a needle, sites like the ankle and foot where injection ulcers are a risk, people who dread needles, and telangiectatic matting, the mesh of new hair-fine vessels that can appear after sclerotherapy.

The evidence sets a threshold. In a randomised comparison of 285 women treated in 2 sessions 8 weeks apart, the 1064 nanometre laser cleared 95% of vessels under 1 millimetre well or very well against 53% for polidocanol, while above 1 millimetre polidocanol edged ahead at 86% to 82%. The Cochrane review of 35 trials with 3,632 participants found no overall difference in clearance between laser and sclerosants, about 40% less hyperpigmentation after laser, and the best clearance when both were combined. In practice most legs get both, needle for the feeders and laser for the fine residue, in 2 to 4 sessions spaced 6 to 12 weeks apart. Expect roughly 150 to 400 EUR or 200 to 500 USD per session, rarely covered by insurance.

Aftercare and the honest list of side effects

After sclerotherapy you walk out of the clinic, literally: 30 minutes of walking a day for the first 1 to 2 weeks keeps the deep veins flowing, while heavy leg training, hot baths, sauna and long-haul flights wait 1 to 2 weeks. Compression stockings of class 1 or 2 (roughly 18 to 32 mmHg) are worn for 1 to 3 weeks depending on the clinic; for the smallest vessels the evidence for long compression is thin and some centres skip it. Laser needs no compression, only cooling on the day and loose clothing.

The treated vessel does not vanish on the spot. After sclerotherapy it darkens, may feel like a firm cord and fades over 3 to 6 weeks; after laser the finest vessels may disappear immediately while larger ones darken and take 1 to 3 months to go. Sun on a treated site drives brown pigment into the skin, so the legs stay covered or under SPF 50 for at least 3 to 4 weeks, and many clinics say 4 to 6, which is why autumn and winter are the sensible seasons for legs.

The side effects have names. Hyperpigmentation, a brown line of iron pigment along the treated vein, affects roughly 10 to 30% of sclerotherapy patients and fades over 6 to 12 months; the Cochrane data show it about 12 times more often than after placebo, and less often after laser. Telangiectatic matting follows in about 5 to 20% and usually clears within 3 to 12 months. Small skin ulcers, allergic reactions and deep vein thrombosis are rare, thrombosis in well under 1% of cases. A clinic will also postpone sclerotherapy over active infection, phlebitis or broken skin at the injection site, and will ask about anticoagulants such as warfarin or a DOAC beforehand, since an injected vessel on blood thinners bruises more and takes longer to settle. Pregnancy is a reason to postpone too: NICE advises against interventional vein treatment during pregnancy except in exceptional circumstances.

What you can do yourself

Movement is the strongest lever, because the calf muscle is the pump that pushes blood back towards the heart. Walking beats standing, standing beats sitting, and anyone who stands or sits for a living gains from a short movement break every 30 to 45 minutes; the Desk Stretch Break ends on a calf raise for exactly that reason. Legs up for 15 minutes in the evening, weight in a healthy range and compression stockings on flights over 4 hours all lower the pressure in the leg veins. Heat does the opposite: sauna, hot baths and sunbathing dilate the vessels.

What none of this does is remove a vessel that already exists, and neither does a cream. Products sold against spider veins stay on the surface; a dilated vessel 1 millimetre below is not reached by anything applied on top. What self-care can do is slow the arrival of the next generation, and that is the honest deal after treatment too: closed vessels stay closed, new ones appear at a rate set by your veins, your work and your genes, and a touch-up every 2 to 5 years is normal for people prone to them. Red vessels on the face follow different rules; see couperose and rosacea.

Signs that call for a vein scan before any cosmetic treatment

Frequently asked

Are spider veins dangerous?

On their own, no: they are dilated vessels under 1 millimetre wide and cause no harm. They can be the visible sign of a leaking valve in a deeper vein, which is why a duplex ultrasound of 15 to 30 minutes belongs before any cosmetic treatment, and why aching, swelling or skin changes on the lower leg deserve a vascular assessment regardless of the look.

Sclerotherapy or laser, which is better for spider veins?

The width of the vessel decides. Below 1 millimetre a 1064 nanometre laser cleared 95% of vessels in a randomised trial against 53% for polidocanol; above 1 millimetre sclerotherapy edged ahead at 86% to 82%, and most legs get both.

How many sessions do spider veins need?

Usually 2 to 4, spaced 6 to 12 weeks apart so that each treated vessel has time to be absorbed before the next assessment. Results are judged after 3 to 6 weeks for sclerotherapy and up to 3 months for laser.

Do spider veins come back after treatment?

A properly closed vessel does not reopen, but new ones form as long as the tendency and the pressure from deeper veins remain. If the scan found reflux that was left untreated, the same patch tends to return within 1 to 2 years; with competent trunk veins a touch-up every 2 to 5 years is typical.

How long do I wear compression stockings after sclerotherapy?

Clinics prescribe anything from 1 to 3 weeks for spider and reticular veins, and NICE limits compression after trunk vein procedures to 7 days. For the smallest vessels the evidence that long compression improves the result is thin, so follow your own clinic's instruction rather than a general rule.

Do creams remove spider veins?

No. A cream stays on the skin surface and cannot reach a dilated vessel 1 millimetre below it. Daily sun protection helps prevent new facial vessels, but an existing spider vein disappears only through sclerotherapy or laser.

Sources

• Nakano LCU et al., Treatment for telangiectasias and reticular veins, Cochrane Database of Systematic Reviews 2021 (PMC) · 35 trials, 3,632 participants; telangiectasias in 41% of women; laser versus sclerosants, hyperpigmentation and matting risk ratios, combination results
• NICE guideline CG168: Varicose veins, diagnosis and management · referral criteria, duplex ultrasound before treatment, treatment order, compression no longer than 7 days, no intervention in pregnancy
• American Academy of Dermatology: How dermatologists treat leg veins · 2 or 3 sclerotherapy sessions, results in 3 to 6 weeks, stockings for 2 to 3 weeks, laser 3 or more sessions, sun protection 3 to 4 weeks
• Ianosi G et al., Comparative study in leg telangiectasias treatment with Nd:YAG laser and sclerotherapy, Exp Ther Med 2019 (PMC) · 285 women, 2 sessions 8 weeks apart; 1064 nm laser 95% clearance under 1 mm versus 53% for polidocanol, 82% versus 86% above 1 mm

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This guide is for general information. It does not replace medical or professional cosmetic advice or an examination.