Chapter 64

### PATIENT STORY

A 40-year-old otherwise healthy school teacher presented with disfiguring spider and reticular veins on the posterior-lateral aspect of her left thigh. Her spider veins appeared in her mid-twenties and worsened with each childbirth. She was concerned about the appearance of this area since she was starting to take her young children to the swimming pool in the summer months. She described no pain but experienced occasional burning and stinging.

Physical examination showed no large varicosities. Her left lateral thigh and popliteal area was covered with a number of 2- to 3-mm reticular veins and by clusters of spider veins. Foam sclerotherapy was chosen as the treatment with good results (Figure 64-1).

###### FIGURE 64-1

Left: Pretreatment photograph of the thigh area with visible reticular and spider veins. Right: Posttreatment appearance of the thigh veins a few weeks following sclerotherapy.

### PATHOPHYSIOLOGY

• An elevated venous pressure in the subdermal capillaries is blamed for spider veins. Valvular incompetence in the larger axial veins and pressure secondary to reflux of blood into the superficial cutaneous capillaries may also cause enlargement of reticular and spider veins.

• Other etiologic factors blamed for varicose and spider veins include aging, sun exposure, hormonal shifts, smoking, alcohol intake, obesity, occupation, heredity, pregnancy, and birth control hormonal medications.

• There is some speculation that endothelial cells and endothelin receptor density and distribution may play a role in the development of varicose veins.1

### CLINICAL FEATURES

• Spider and reticular veins are most often located on the legs and thighs in women, although they occur on the nose and face as well. Men can develop spider veins as well.

• Although asymptomatic for the most part, some patients with large reticular and extensive spider veins complain of burning, stinging, swelling, throbbing, cramping, and leg fatigue.

• A bluish subdermal reticular pattern of veins may be visible in patients with pale translucent skin.

### DIAGNOSIS

• A variety of small veins are visible on physical examination. These small vessels include telangiectasia, venulectasia, and reticular ecstasias.

• Telangiectasias are flat red vessels, very close to the skin surface, and less than 1 mm in diameter.

• Venulectasias are bluish in color, sometimes distended and barely above the skin surface, and less than 2 mm in diameter.

• Reticular veins have a dark bluish or cyanotic hue and are between 2 and 4 mm in diameter.

• Varicose veins are generally larger (>3-4 mm in diameter), protrude above the skin surface, and compress easily with slight manual pressure.

### DIFFERENTIAL DIAGNOSIS

• Dermatologic conditions with or without pigmentation can be mistaken for small varicose veins.

• Capillary malformations associated with congenital venous malformations can also be confused with reticular and spider veins.

• Cellulitis.

• Stasis dermatitis.

• Osler-Weber-Rendu syndrome or hereditary hemorrhagic ...

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