Telangiectasia, also known as “spider veins,” is caused by permanent, abnormal dilation of end vessels, venules mainly, but also of capillaries and arterioles of the sub papillary plexus.¹ Telangiectasia was first described in 1807 by Von Graf. The term comes from the words telos meaning end, angeion meaning vessel, and entasis meaning dilation.^2,3

It presents as red or blue tinted veins that are visible on the skin’s surface depending on if it is venous or arterial. Typically, venous telangiectasia are blue tinted, 1-3 mm in diameter, and raised, while arterial telangiectasia are usually red tinted, below 1mm in diameter, and flat.³ Unlike varicose veins, this condition isn’t known to cause adverse health effects and most patient complaints surround aesthetic concerns; however, this condition may cause recurrent pain and is associated with several disease processes.³ The exact cause of telangiectasia is unknown. The causes may be genetic, environmental, or a combination of both. Possible causes can include the following⁴:

• Alcoholism
• Pregnancy
• Aging
• Habitual Corticosteroid Use
• Scleroderma
• Dermatomyosisitis

Smoking as well as patient history of venous thromboembolism (VTE) are evidenced to contribute to spider vein development.^3,5 Literature regarding spider vein epidemiology agree that most adults will eventually develop some form of spider veins during their lifetime.³ Women have been found to be 4 times more likely, with history of pregnancy contributing to likelihood. Patient history of chronic venous disease (CVD), including varicose veins or stasis dermatitis, also contribute to risk.⁶Diseases associated with telangiectasia include⁴:

• Ataxia-telangiectasia
• Bloom syndrome
• Cutis marmorata telangiectasia congenital
• Hereditary hemorrhagic telangiectasia
• Klippel-Trenaunay-Weber syndrome
• Nevus flames such as port-wine stain
• Rosacea
• Sturge-Webber Disease
• Xeroderma pigments
• CREST syndrome
• Systemic Lupus Erythematosus

A Note on the CEAP Classification

The Clinical, Etiological, Anatomical, and Pathological (CEAP) classification system was developed to standardize the identification of the extent and presentation of CVD. Understanding the CEAP classification system is vital to assess patients with suspected CVD and prevent subsequent venous ulcers.^3,7 Notably, telangiectasia is featured in one of the 7 main clinical categories^3,7:

• C0 No visible or palpable signs of venous disease
• C1 Telangiectasia or reticular veins
• C2 Varicose veins
• C2r Recurrent Varicose veins
• C3 Edema
• C4 Changes in skin and subcutaneous tissue secondary to CVD
  • C4a Pigmentation or eczema
  • C4b Lipodermatosclerosis or atrophie blanche
  • C4c Corona phlebectatica
• C5 Healed venous ulcer
• C6 Active venous ulcer

It is important to note that the clinical or “C” component of this system is meant to describe the severity of venous disease states and NOT reflect changes in severity over time. Confusion may arise when this classification system is used to reflect the progression of CVD, rather than describing specific presentation in a point in time.⁷ Therefore, if a patient has telangiectasia or C1, it is not predictive of increasing CVD severity.⁷

The 2020 update to the CEAP classification specifies where telangiectasia presence is indicative of other venous disease states, such as corona phlebectatica.⁷ Blue telangiectasia under the malleolar areas extending equal or superior to half the length of the foot, usually with additional presence of stasis spot or perivenous pigmentation, indicates corona phlebectatica, according to the 2020 update.⁷ Corona phlebectatica is designated by C4c in the CEAP classification system.⁷

Treatment/Management

Treatment for spider veins includes⁸:

Sclerotherapy

Sclerotherapy is a treatment for spider veins where sclerosis agents are injected into the vessels with a 30-gauge needle under ultrasound guidance. Sclerosis agents can be a liquid or foam. Common side effects may include transient hyperpigmentation, ulceration, sloughing, allergy, thrombophlebitis, swelling, and pain. Thromboembolic events, anaphylaxis, and transient visual disturbance may also occur but are rare.⁹ This method can also be used to treat varicose veins.³

Intense Pulse Light Treatment (IPL)

If the patient’s spider veins have a diameter less than that of a 30-gauge needle, laser and intense pulse light IPL treatment can be implemented. These therapies are non-invasive, as the light energy is absorbed by the hemoglobin in the damaged vessels. The light energy heats up and occludes vessels secondary to thrombus formation by photocoagulation.^3,10

IPL is relatively safe and tolerable, however, it may be beneficial to avoid in patients with a recent sunburn, pregnant or breastfeeding women, and patients with a previous history of herpes simplex virus (HSV) infection.³

Thermocoagulation

Similar to IPL, thermocoagulation uses heat and is minimally invasive. Instead of light energy, this therapy uses radio frequency administered through a small needle to cause endothelial damage to vessels.^3,9

Microphlebectomy

Microphlebectomy uses hooks to eradicate veins.¹² Since it uses small incisions or needle punctures to achieve venous extraction, microphlebectomy is less likely to leave scarring or residual hyperpigmentation.^3,12

Conclusion

Spider veins are usually asymptomatic and can be caused by a variety of underlying conditions. Patients that have chronic venous insufficiency can be at a higher risk for the development of telangiectasia.

Although the treatment of spider veins is often considered cosmetic, in severe cases there is a higher chance for the development of skin ulcers and thrombophlebitis.¹³ Some evidence suggests that compression stockings may be of some benefit in preventing new spider veins from forming after treatment.¹⁴

References

1. R Katta et al. Angioma serpiginosum with extensive cutaneous involvement. J Am Acad Dermatol. 2000; 42:384-385. doi: 10.1016/s0190-9622(00)90119-1.
2. Merlen JF. [Red telangiectasis, blue telangiectasis]. Phlebologie.1970;23(2):167-74.
3. Sandean DP, Winters R. Spider Vein. In: StatPearls [Internet].Treasure Island (FL): StatPearls Publishing; 2023: https://www.ncbi.nlm.nih.gov/books/NBK563218/
4. Kern P. Pathophysiology of telangiectasias of the lower legs and its therapeutic implication: a systematic review. Phlebology. 2018;33(4):225-233
5. Gourgou S, Dedieu F, Sancho-Garnier H. Lower limb venous insufficiency and tobacco smoking: a case-control study. Am J Epidemiol. 2002;155(11):1007-15.
6. Schwartz L, Maxwell H. Sclerotherapy for lower limb telangiectasias. Cochrane Database Syst Rev. 2011;2011(12):CD008826.
7. Hong KP. The 2020 Update of the CEAP Classification: Updated Contents and Background. Ann Phlebology. 2022;20(1):19-23. https://doi.org/10.37923/phle.2022.20.1.19
8. Aydın U, Engin M, Turk T, Ata Y. The effectiveness of different treatment methods in isolated telangiectasia and reticular vein treatment: a single-center prospective randomized study. Phlebology. 2022;37(1):26-32.
9. Parlar B, Blazek C, Cazzaniga S, Naldi L, Kloetgen HW, Borradori L, Buettiker U. Treatment of lower extremity telangiectasias in women by foam sclerotherapy vs. Nd:YAG laser: a prospective, comparative, randomized, open-label trial. J Eur Acad Dermatol Venereol. 2015;29(3):549-54.
10. Gade A, Vasile GF, Rubenstein R. Intense Pulsed Light (IPL) Therapy. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023: https://www.ncbi.nlm.nih.gov/books/NBK580525/
11. Burleva EP, Ektova MV, Belentsov SM, Chukin SA, Makarov SE, Veselov BA. Treatment of lower extremity telangiectasias by thermocoagulation method using TS-3000 apparatus. Article in Russian. Ambulatornaya khirurgiya. 2018;(1-2):72-79.
12. Ramelet AA. Phlebectomy. Technique, indications and complications. Int Angiol. 2002;21(2 Suppl 1):46-51
13. IanoȘi NG, Neagoe CD, Tutunaru CV, et al. Single blind, randomised study regarding the treatment of the telangiectasia of the lower limbs (C1EAP) using polidocanol 0.5%, 1%, and Nd:YAG laser. Curr Health Sci J. 2020;46(2):141-149.
14. Kern P, Ramelet AA, Wütschert R, Hayoz D. Compression after sclerotherapy for telangiectasias and reticular leg veins: a randomized controlled study. J Vasc Surg. 2007;45(6):1212-6.

About the Author

Emily Greenstein, APRN, CNP, CWON-AP, FACCWS is a Certified Nurse Practitioner at Sanford Health in Fargo, ND. She received her BSN from Jamestown College and her MSN from Maryville University. She is certified as an Adult-Gerontology Nurse Practitioner through the American Academy of Nurse Practitioners. She has been certified in wound and ostomy care through the WOCNCB for the past 12 years. At Sanford she oversees the outpatient wound care and is co-director for the limb preservation program. She currently serves as the President elect for the North Central Region Wound, Ostomy, and Continence Society. Emily has served as an expert reviewer for the WOCN Society and the Journal for WOCN. Her main career focus is on the advancement of wound care through evidence-based research.