By Diane Donofrio Angelucci, contributing writer, October 01, 2013
According to the Vascular Disease Foundation, six million people in the United States have skin changes associated with chronic venous insufficiency.
Although venous disease is often addressed by a range of medical specialists, because of these skin changes, dermatologists are often on the front line in detecting this condition.
Elevated blood pressure in the superficial venous system that occurs during walking, which results from a clot or other venous system destruction with valve breakdown, can result in leaky veins, said David Margolis, MD, professor of dermatology and epidemiology at the University of Pennsylvania. Therefore, varicose veins, edema, dermatitis, ulcers, and blood staining of the skin can occur.
“Dermatologists are often trained to take care of wounds so they understand the concepts of good wound care, sometimes better than others,” Dr. Margolis said. However, an integrated approach — drawing on the expertise of vascular surgeons, podiatrists, and other specialists — remains important.
Diagnosing venous disease
A careful patient history and examination reveal critical details. Often surfacing in women in their 40s and men in their 60s and 70s, venous insufficiency occurs more commonly in the Western world. Risk factors include family history, a history of deep vein thrombosis, obesity, and multiple pregnancies, among others. Those required to stand for lengthy periods at work may also be more prone to this condition if they are predisposed.
“We do more full-skin exams than any other specialty,” said Girish (Gilly) Munavalli, MD, MHS, medical director of Dermatology, Laser, and Vein Specialists of the Carolinas, PLLC, in Charlotte, N.C., and assistant professor in the Wake Forest University department of dermatology, giving dermatologists a unique opportunity to evaluate the vascular status of their patients. [pagebreak]
On physical examination, clinicians should search for signs such as bulging veins, stasis dermatitis, skin breakdown, and swelling. “Anything that you see should prompt you to just to ask a couple of simple questions, like, Do you have a family history of varicose veins?’ or Do your legs bother you? Are they achy?’” Dr. Munavalli said.
When spider veins appear on the calf, it’s important to examine the back of the patient’s legs. “If you don’t look at the back of the knee or thighs, you’re not going to realize that they have a varicose vein there that’s contributing to the spider veins lower down,” said Margaret Weiss, MD, of the Maryland Laser, Skin, and Vein Institute in Hunt Valley, Md.
“When groups of spider veins and associated blue veins are on the medial side of the leg, there’s a high probability, probably 80 to 90 percent chance, that they’re coming from a leak in the great saphenous vein,” said Robert Weiss, MD, director of the Maryland Laser, Skin, and Vein Institute. However, he continued, if they’re on the lateral part of the leg, they can usually be attributed to the lateral subdermal venous system.
Diabetes, hypertension, and other conditions can mask the signs of venous disease in the lower legs, Dr. Munavalli said, because they cause lower leg skin changes and potentially leg swelling. Lymphedema can demonstrate similar characteristics, such as edema, skin changes, heaviness, and pain, he explained. “Venous disease onset is insidious and can also manifest with episodic swelling of the legs and stasis dermatitis around the areas of bulging veins,” he said.
Duplex ultrasound is an essential tool in diagnosis. “Most dermatologists don’t have this tool in their offices, so you really need to develop a referral relationship with a vein center or another colleague who does a lot of superficial venous ultrasounds,” Dr. Munavalli said, such as a vascular surgeon. Duplex ultrasound “is non-invasive, quick, and gives information on abnormal flow in the veins,” he said. It can also measure the abnormally large veins that result from longstanding distension. [pagebreak]
Weighing treatment options
A decade ago, patients with vein damage often needed vein stripping; however, outpatient treatments have emerged that reduce the need for more invasive procedures.
Dr. Robert Weiss and Mitchel Goldman, MD, were key developers of endovenous ablation technology, which destroys the vein so it eventually will become reabsorbed. “That really revolutionized the treatment of leg veins, and because so many people now have access to that, we predict that the number of people with leg ulcers from chronic venous insufficiency is going to go way down and it’s actually going to reduce our health care costs,” Dr. Robert Weiss said. He explained that patients often delayed seeking the stripping procedure, but endovenous ablation, using diode or Nd-YAG lasers, is performed with a single puncture.
Major leg veins with leaky valves typically are treated with endovenous ablation (laser or radiofrequency), Dr. Margaret Weiss explained. “After that major leakage is shut down, then one can generally treat remaining varicose veins either with sclerotherapy or sometimes with ambulatory phlebectomy,” she said. “Many times telangiectasias don’t have significant underlying reflux and they can either most commonly get treated with sclerotherapy or they can be treated sometimes with lasers.”
Another advance in the treatment of abnormal veins, the sclerosant polidocanol (Asclera), was cleared by the U.S. Food and Drug Administration in 2010 to treat spider veins and small varicose veins. “Now that it’s available, it actually is a great benefit to patients,” Dr. Robert Weiss said physicians who previously used polidocanol had to obtain it from compounding pharmacies, but today they can use a true pharmaceutical grade version. Peterson and colleagues reported a study comparing polidocanol and hypertonic saline sclerotherapy in the August 2012 issue of Dermatologic Surgery. In this study (funded by Merz Aesthetics, which distributes Asclera in the U.S.), both agents were effective, but patients experienced less pain with the new formulation. [pagebreak]
“Foam sclerotherapy has been a big advance,” Dr. Robert Weiss added. (Injecting the sclerosant as foam rather than a liquid allows it to make contact with a higher percentage of the inside of the vein.) However, he noted, the FDA differentiates between injecting a sclerosant as a liquid or a foam, so foam treatment is currently off label. “What [foam] allows you to do is to treat more precisely because you can see where the foam displaces the blood,” he said. “You can do it just as far as you want and then stop. The other big advantage is that, because these are all microbubbles, on the surface of each microbubble you have the full concentration of the solution without being diluted by blood, so it makes it a more effective sclerosing agent and more precise.”
New sclerosants are working their way through the pipeline, according to Dr. Munavalli, who directed a forum on treatment of varicose and telangiectatic veins at the American Academy of Dermatology’s 2013 Annual Meeting. “Some of the things coming down the line are new, more potent sclerotherapy agents that are better able to destroy the vein without spreading outside of that area,” he said.
Treatment side effects
Major adverse events from sclerotherapy are solution dependent, Dr. Robert Weiss said. “You can get a little skin breakdown or ulceration where the solution was injected. It’s highly unlikely, though, with the newer solutions,” he said. Because he believes hypertonic saline carries the highest risk of skin breakdown, he tends to avoid it.
For patients with widespread networks of problem veins, Dr. Margaret Weiss encourages testing with varying concentrations of solutions and foam vs. non-foaming agents to determine whether a patient is susceptible to hyperpigmentation or matting.
“Matching the concentration of the sclerosing solution to the size of the vessel is really important,” Dr. Margaret Weiss said. “In other words, you want to use the minimum concentration of sclerosant for a particular size vessel and then have the patient wear compression stockings after the treatment for anywhere from one to three weeks.” Post-treatment compression helps reduce the risk of hyperpigmentation. Meticulous attention to technique is also essential so the solution does not leak into the surrounding skin, resulting in ulceration, she explained. [pagebreak]
Dr. Margaret Weiss also advised using the smallest amount of solution needed. “The risk of a deep blood clot is fortunately extremely low with sclerotherapy and using the appropriate amount of solution and compression stockings, having the patients... ambulatory after their treatment, that’s helpful in reducing that risk,” she said.
Facilitating wound healing
Venous disease can lead to ulcers. Because it is not the only cause, though, clinicians should start the wound-healing process by ruling out other potential causes of ulceration. “Sometimes there are mimickers of venous ulcers; anything from cancer to inflammatory conditions can sometimes look like a venous ulcer,” said Robert S. Kirsner, MD, PhD, professor, vice chairman, and Stiefel Laboratories Chair in the department of dermatology and cutaneous surgery, and chief of dermatology at the University of Miami Hospital School of Medicine.
In addition to performing a physical examination and vascular or arterial studies, clinicians may also perform biopsies to exclude other wound causes if a wound is not improving.
Primary wound dressings usually help keep the wounds moist, and some ulcers may need debridement especially when chronic ulcers have devitalized tissue, Dr. Margolis said.
Dr. Kirsner explained that compression wraps are the mainstay of treatment for venous ulcers. “The problem is that it is a difficult treatment for patients because they are meant to be left on so it does affect their lifestyle,” he said.
To achieve optimal results with compression wraps, it’s important to choose the correct wrap and ensure it will not create problems; for example, if elastic full-strength wraps are used in patients with inadequate arterial flow, skin necrosis could occur, Dr. Kirsner said. [pagebreak]
Two types of compression wraps exist: inelastic and elastic. Inelastic wraps harden, providing compression when the patient walks, whereas elastic wraps constantly squeeze the leg. “So typically elastic compression is better than inelastic compression, and systematic reviews have confirmed that multilayered compression bandages are better than a single layer of compression,” Dr. Kirsner said.
“For the average-sized wound (<10 cm2), about a 30 to 40 percent size reduction in a month is a good indicator of whether or not the wound is going to have a chance to go on to heal,” Dr. Kirsner continued. If the wound hasn’t reduced in size by one month of treatment, the clinician should consider adding one of several available adjunctive therapies that have been successfully used with compression wraps to speed healing. “There have been studies with aspirin and with pentoxifylline given orally that will speed the healing of venous ulcers when used with compression wraps,” Dr. Kirsner said. Jull and colleagues reported on pentoxifylline in treating venous ulcers in the 2012 Cochrane Database of Systematic Reviews. “There are also biologic and synthetic extracellular matrices or acellular constructs that have been shown in studies to speed the healing,” Dr. Kirsner said. Kelechi and colleagues investigated the use of a poly-N-acetyl glucosamine nanofiber-derived wound-healing technology in a pilot study reported in the June 2012 issue of the Journal of the American Academy of Dermatology, and Mostow and colleagues reported on a biomaterial derived from porcine small-intestine submucosa in the May 2005 issue of the Journal of Vascular Surgery. In addition, Dr. Kirsner explained, bilayered engineered cellular constructs grown in the laboratory have level 1 evidence to support their use.
Reducing venous ulcers
Dr. Margaret Weiss hopes venous ulcers eventually become a thing of the past. If venous insufficiency is treated before changes such as dermatitis, chronic edema, and skin breakdown occur, clinicians can help prevent these consequences, “so they wouldn’t get a wound that needed to heal,” she said.
Editor’s note: Dr. Margaret Weiss has no financial interests related to her comments. Dr. Kirsner is a consultant for 3M, Healthpoint Biotherapeutics, and Organogenesis. Dr. Margolis has served as a consultant for Healthpoint Biotherapeutics, Organogenesis, and Shire Regenerative Medicine; he also has served on an advisory board for Celleration. Dr. Munavalli has been an investigator for BTG (makers of Varisolve) and CoolTouch, a laser used to perform endovenous ablation, and is medical director of Merz Aesthetics, which produces Asclera. Dr. Robert Weiss previously served as a speaker for Merz Aesthetics.