Harvard Women's Health Watch

Minimally invasive treatments for bothersome leg veins

Treating enlarged leg veins can improve their appearance and reduce the risk of swelling, aching, and other problems.

If you have varicose veins — those dark blue or purple leg veins that bulge above the skin's surface — you may dread wearing beachwear and other clothes that expose your legs. With summer just a few months away, this may be a good time to do something about that. But it's not just a cosmetic consideration. Varicose veins can cause pain and discomfort and even, in rare cases, bleeding leg sores. Treating enlarged leg veins can relieve discomfort and prevent complications.

The older, surgical treatment for varicose veins was "stripping" — removing leg veins through incisions under general anesthesia. Surgery has been largely replaced by less invasive options that include injections, laser, and radiofrequency energy. Growing numbers of vein treatment centers throughout the United States are making these treatments available to more women. The approach that's best for you depends on the size, type, and location of your varicose veins.

Weak valves, pooling blood

Leg veins have a tough job: they must propel oxygen-depleted blood all the way back to your heart, working against gravity and the pressure of your body weight. These veins have one-way valves that prevent blood from flowing backward (see "Anatomy of a varicose leg vein"), but the valves can weaken and stop working properly, especially as we age. As a result of these changes, blood can pool in the veins immediately under the skin, causing them to enlarge and become less elastic.

Anatomy of a varicose leg vein

illustration of normal leg vein and varicose vein

Normally, blood in the leg is moved upward toward the heart by one-way valves, which prevent blood from flowing backward (A). In a varicose vein (), the valves are deformed and don't close properly, so the blood flows backward, pools, and enlarges the vein.

There are several types of enlarged veins: varicose, reticular, and spider veins. Varicose veins are at least one-tenth of an inch in diameter and may be as large as three-quarters of an inch. They often resemble twisted ropes and can form anywhere from the thigh to the ankle. You're most likely to feel the chief symptoms — aching, burning, pressure, heaviness, or weakness in the legs — after standing or sitting for a long period of time. At night you may develop a painful muscle spasm in your calf (a charley horse). Your feet and ankles may swell, and the skin around the affected veins may become dry and itchy, or develop a rash or a brownish or bluish discoloration. Larger veins don't necessarily mean more serious symptoms, and symptoms may develop even before the veins become prominent.

Reticular veins, also known as blue veins or feeder veins, are smaller than varicose veins but may also have a ropy appearance. They occur mainly on the back of the leg, usually around the knee. Reticular veins may branch into (or feed) spider veins, also called telangiectasias, which are smaller than reticular veins and don't bulge or cause discomfort. They look like red or blue spiderwebs on the skin's surface and may occur on the face as well as the legs.

Selected resources

American Society for Dermatologic Surgery

American College of Radiology/Radiological Society of North America

Society of Interventional Radiology
800-488-7284 (toll-free)

The American Venous Forum

Who gets varicose veins?

Age is the most common risk factor. More than 40% of women over age 50 and 75% of women over age 70 have varicose veins. Not only do blood vessels weaken with age, so do calf muscles, which normally help squeeze veins and send blood back toward the heart as you walk.

Other risk factors that can predispose you to varicose veins include the following:

Gender. Women are slightly more susceptible to varicose veins than men. Pregnancy may be one reason: increased blood volume, extra weight, and greater abdominal pressure subject the leg veins to more wear and tear. The more full-term pregnancies a woman has had, the greater her risk. Hormones can also cause blood vessels to dilate, and there's some evidence that taking either oral contraceptives or hormone therapy increases the likelihood of developing varicose veins.

Heredity. Varicose veins tend to run in families, probably because of inherited weakness in vein walls or valve functioning.

Occupation. A large Danish study found that women who spent more than 75% of their working time standing or walking were nearly twice as likely to be treated for varicose veins as women who spent fewer working hours on their feet.

Weight. Excess weight, particularly around the middle, puts added pressure on leg veins. Moderately overweight women are more likely to have varicose veins than their thinner counterparts, and the risk is tripled in obese women.

Self-care approaches

Unless you have symptoms, there's no reason to treat your varicose veins. If you do have symptoms, the following strategies may be enough to ease your discomfort and avoid or delay the need for stronger measures:

Put your feet up. Several times a day, take a 15-minute rest with your legs raised above the level of your heart so that your veins don't have to work against gravity.

Change leg activity. If you can, avoid prolonged sitting or standing. If you do sit or stand for long periods, take frequent brisk walking breaks. Don't sit with your legs crossed.

Be active. Get regular exercise, such as brisk walking, to improve circulation and tone calf muscles, which help move blood through the veins.

Take a pain reliever. Acetaminophen, aspirin, or ibuprofen may relieve occasional mild aching from varicose veins.

Wear compression stockings. Elastic stockings put pressure on leg veins and prevent blood from flowing backward. If symptoms are mild to moderate, regular support stockings or over-the-counter compression stockings may suffice. If symptoms are more severe, your clinician will prescribe a graduated compression stocking that applies decreasing pressure from the ankles to the thighs. You should put the stockings on before you get out of bed in the morning. Unless you have already developed certain complications, your insurance company will probably require you to try compression stockings for several months before it authorizes payment for more invasive treatment.

Loosen up. Don't wear tight clothing around the waist or legs.

Minimally invasive approaches

If you've tried self-help (see "Self-care approaches") without much success, you may want to consider a minimally invasive procedure. If your needs are purely cosmetic, you'll need to pay out-of-pocket for treating spider veins and possibly larger veins. Therapy is considered medically necessary if your symptoms limit your everyday activities, or if the veins have ruptured or caused sores that are difficult to treat.

Vein procedures are performed by many different specialists, including dermatologists, interventional radiologists, vascular surgeons, and plastic surgeons based in hospitals or medical centers. Specialized vein treatment centers may also be available in your area. It's important to check the credentials and training of the physician doing the procedure, according to Dr. Emily J. Fisher, chief of laser and cosmetic dermatology at Lahey Clinic in Lexington, Mass. She points out that you may need an ultrasound to check for underlying problems in the deeper leg veins. She also recommends that you make sure the physician performing the vein procedure can address complications or unexpected findings or refer you to someone who can.

Minimally invasive options for treating leg veins include the following:

Sclerotherapy. Also known as injection therapy, this treatment is usually the first choice for spider veins, reticular veins, and small varicose veins. The physician injects a chemical irritant — either a liquid or foam — into the vein, making it swell, stick together, and seal shut. Your circulation isn't impaired because healthy blood vessels nearby compensate for the one that's been closed. Until recently, most doctors used a detergent-like substance called sodium tetradecyl sulfate for sclerotherapy. But in 2010, the FDA approved a new agent, called polidocanol (Asclera) for use on spider veins and very small varicose veins. Both agents work equally well; both are slightly painful and may cause temporary swelling and bruising. There is a very small risk of an allergic reaction, which may be more likely in women with a history of severe allergies or asthma. So be sure to let your clinician know if you have allergies.

Sclerotherapy is usually performed by a dermatologist and generally requires more than one session, since each vein typically must be injected one to three times. Sessions last from 15 minutes to an hour; no anesthesia is required. After each session, you'll need to wear bandages and compression stockings for a week or two. Once blood is no longer flowing through the vein, scar tissue develops and the vein gradually fades. Brown lines may develop in the treated area, but these, too, usually fade.

Surface therapy (laser). Spider veins, reticular veins, and small varicose veins can be treated with a laser applied to the surface of the skin. Lasers emit a specific wavelength of light that heats up and damages the vein without injuring nearby tissues. You will need to wear protective eyewear to safeguard your eyes against any stray laser beams. Some women prefer laser therapy to injections because it doesn't involve needles, but that doesn't mean it's painless — you'll feel a strong pinching sensation when the laser is activated. Numbing gels or creams can lessen the sting.

The treatment usually lasts 15 to 20 minutes and doesn't require any bandages. You may experience temporary bruising, itching, or swelling, and some women notice changes in skin color (either darkening or lightening) in the treated area, which occurs if the laser affects the skin's pigment. You'll need to wear compression stockings for several days afterward. Your symptoms may improve within a week or two following laser treatment, but changes in appearance take longer. Surface laser therapy may work better than sclerotherapy for veins that are too narrow to successfully inject, such as very small spider veins. It's also used for people who are allergic to sclerosing agents or who are afraid of needles.

Internal therapy (laser or radiofrequency). Also known as endovenous techniques, these methods are used to treat deeper varicose veins. The troublesome vein is located with ultrasound, and a small catheter is inserted into the vein (see "Endovenous treatment"). The catheter emits either laser or radiofrequency energy, which shrinks and seals the vein. As with other treatments, surrounding healthy veins maintain normal blood flow. Swelling and pain can occur, and you should wear compression stockings for at least two weeks. Surface veins connected to the treated vein usually shrink after the treatment, but if not, they can be treated with "touch-up" sclerotherapy.

Endovenous treatment

illustration of endovenous treatment using laser

After the varicose vein has been located with ultrasound, a catheter is inserted into the vein (A) through a small opening in the skin. The catheter delivers either laser or radiofrequency energy to the vein wall, heating it and causing the vein to collapse. The vein closes as the catheter is withdrawn ().

Laser and radiofrequency have similar long-term success rates (recurrence rates are around 10%), so the choice may depend mainly on the physician's experience with one or the other procedure.