Telangiectasia

Telangiectasia
Characteristic lip telangiectases.
Classification and external resources
Specialty	Dermatology
ICD-10	G11.3, I78.0, M34.1
ICD-9-CM	362.15, 448.0
DiseasesDB	27395
MedlinePlus	003284
MeSH	D013684

Telangiectasias /tɛlˌæn.dʒiː.ɛkˈteɪ.zi.ə/ also known as spider veins or angioectasias, are small dilated blood vessels^[1] near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter.^[2] They can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin. They can also develop on the legs, although when they occur on the legs, they often have underlying venous reflux or "hidden varicose veins" (see "Venous reflux" below). When found on the legs, they are found specifically on the upper thigh, below the knee joint, and around the ankles. Many patients who suffer with spider veins seek the assistance of physicians who specialize in vein care or peripheral vascular disease. These physicians are called vascular surgeons or phlebologists. More recently interventional radiologists have started treating venous problems.

Some telangiectasia are due to developmental abnormalities that can closely mimic the behaviour of benign vascular neoplasms. They may be composed of abnormal aggregations of arterioles, capillaries, or venules. Because telangiectasias are vascular lesions, they blanch when tested with diascopy.

Telangiectasia is a component of the CREST variant of scleroderma, also known today as limited scleroderma (CREST is an acronym that stands for calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia.)

Causes

The causes of telangiectasia can be divided into congenital and acquired factors.

Congenital causes

Goldman states that "numerous inherited or congenital conditions display cutaneous telangiectasia".^[2] These include:

• Naevus flammeus (port-wine stain)
• Klippel-Trenaunay syndrome
• Maffucci's syndrome (multiple endochondromas & hemangiomas)
• Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)
• Ataxia-telangiectasia
• Sturge-Weber syndrome, a nevus formation in the skin supplied by the trigeminal nerve and associated with facial port-wine stains, glaucoma, meningeal angiomas and mental retardation..

Acquired causes

• Cushing's syndrome

Venous hypertension

In the past, people used to think that leg varicose veins or telangectasia were caused by high venous pressure or "venous hypertension". However it is now understood that venous reflux disease is usually the cause of these problems (see above for reference for "venous reflux".^[3]

Telangiectasia in the legs is often related to the presence of venous reflux within underlying varicose veins. Flow abnormalities within the medium-sized veins of the leg (reticular veins) can also lead to the development of telangiectasia. Factors that predispose to the development of varicose and telangiectatic leg veins include

• Age: The development of spider veins may occur at any age but usually occurs between 18 and 35 years, and peaks between 50 and 60 years.
• Gender: It used to be thought that females were affected far more than males. However research has shown 79% of adult males and 88% of adult females have leg telangectasia (spider veins).^[4]
• Pregnancy: Pregnancy is a key factor contributing to the formation of varicose and spider veins. The most important factor is circulating hormones that weaken vein walls. There's also a significant increase in the blood volume during pregnancy, which tends to distend veins, causing valve dysfunction which leads to blood pooling in the veins. Moreover, later in pregnancy, the enlarged uterus can compress veins, causing higher vein pressure leading to dilated veins. Varicose veins that form during pregnancy may spontaneously improve or even disappear a few months after delivery.
• Lifestyle/Occupation: Those who are involved with prolonged sitting or standing in their daily activities have an increased risk of developing varicose veins. The weight of the blood continuously pressing against the closed valves causes them to fail, leading to vein distention.

Other acquired causes

Acquired telangiectasia, not related to other venous abnormalities, for example on the face and trunk, can be caused by factors such as

• Acne rosacea
• Blepharitis^[5]
• Environmental damage such as that caused by sun or cold exposure
• Trauma to skin such as contusions or surgical incisions.
• Radiation exposure such as that experienced during radiotherapy for the treatment of cancer
• Chemotherapy
• Carcinoid syndrome
• Limited systemic sclerosis/scleroderma (a Scleroderma sub-type)
• Chronic treatment with topical corticosteroids may lead to telangiectasia.^[6]
• Spider angiomas are a radial array of tiny arterioles that commonly occur in pregnant women and in patients with hepatic cirrhosis and are associated with palmar erythema. In men, they are related to high estrogen levels secondary to liver disease.
• Tempi syndrome

Treatment

Before any treatment of leg telangectasia (spider veins) is considered, it is essential to have Duplex ultrasonography the test that has replaced Doppler Ultrasound. The reason for this is that there is a clear association between leg telangectasia (spider veins) and underlying venous reflux.^[7] Research has shown that 88-89% of women with telangectasia (spider veins) have refluxing reticular veins close,^[8] and 15% have incompetent Perforator veins nearby.^[9] As such, it is essential to both find and treat underlying venous reflux before considering any treatment at all.

Sclerotherapy is the "gold standard" and is preferred over laser for eliminating telangiectasiae and smaller varicose leg veins.^[10] A sclerosant medication is injected into the diseased vein so it hardens and eventually shrinks away. Recent evidence with foam sclerotherapy shows that the foam containing the irritating sclerosant quickly appears in the patient's heart and lungs, and then in some cases travels through a patent foramen ovale to the brain.^[11] This has led to concerns about the safety of sclerotherapy for telangectasias and spider veins. In some cases stroke and transient ischemic attacks have occurred after sclerotherapy.^[12] Varicose veins and reticular veins are often treated before treating telangiectasia, although treatment of these larger veins in advance of sclerotherapy for telangiectasia may not guarantee better results.^[13][14][15] Varicose veins can be treated with foam sclerotherapy, endovenous laser treatment, radiofrequency ablation or open surgery. The biggest risk, however, seems to occur with sclerotherapy, especially in terms of systemic risk of DVT, pulmonary embolism, and stroke.

Another issue that arises with the use of sclerotherapy to treat spider veins is staining, shadowing, telangetatic matting and ulceration. In addition, incompleteness of therapy is common, requiring multiple treatment sessions.

Telangiectasias on the face are often treated with a laser. Laser therapy uses a light beam that is pulsed onto the veins in order to seal them off, causing them to dissolve. These light-based treatments require adequate heating of the veins. These treatments can result in the destruction of sweat glands, and the risk increases with the number of treatments.

References

1. "telangiectasia" at Dorland's Medical Dictionary
2. Goldman, Mitchel P (1995). Sclerotherapy treatment of varicose and telangiectatic leg veins (2nd ed.). St. Louis: Mosby. ISBN 0-8151-4011-8.
3. Whiteley (2011). "Understanding Venous Reflux – the cause of varicose veins and venous leg ulcers".
4. Ruckley, C.V.; Evans, C.J.; Allan, P.L.; Lee, A.J.; Fowkes, F.G.R. (2008). "Telangiectasia in the Edinburgh Vein Study: Epidemiology and Association with Trunk Varices and Symptoms". European Journal of Vascular and Endovascular Surgery 36 (6): 719–24. doi:10.1016/j.ejvs.2008.08.012. PMID 18848475.
5. Lindsley, Kristina; Matsumura, Sueko; Hatef, Elham; Akpek, Esen K (2012). "Interventions for chronic blepharitis". Cochrane Database of Systematic Reviews 5: CD005556. doi:10.1002/14651858.CD005556.pub2. PMC 4270370. PMID 22592706.
6. Johnson, B. A.; Nunley, J. R. (2000). "Treatment of seborrheic dermatitis". American family physician 61 (9): 2703–10, 2713–4. PMID 10821151.
7. Ruckley, C. V.; Allan, P. L.; Evans, C. J.; Lee, A. J.; Fowkes, F. G. R. (2011). "Telangiectasia and venous reflux in the Edinburgh Vein Study". Phlebology 27 (6): 297–302. doi:10.1258/phleb.2011.011007. PMID 22106449.
8. Weiss, Robert A.; Weiss, Margaret A. (1993). "Doppler Ultrasound Findings in Reticular Veins of the Thigh Subdermic Lateral Venous System and Implications for Sclerotherapy". The Journal of Dermatologic Surgery and Oncology 19 (10): 947–51. doi:10.1111/j.1524-4725.1993.tb00983.x. PMID 8408914.
9. Somjen, George M.; Ziegenbein, Robert; Johnston, Andrew H.; Royle, John P. (1993). "Anatomical Examination of Leg Telangiectases with Duplex Scanning". The Journal of Dermatologic Surgery and Oncology 19 (10): 940–5. doi:10.1111/j.1524-4725.1993.tb00982.x. PMID 8408913.
10. Sadick N, Sorhaindo L (2007). "16. Laser Treatment of Telangiectatic and Reticular Veins". In Bergan, John J. The Vein Book. Amsterdam: Elsevier Academic Press. p. 157. ISBN 0-12-369515-5.
11. Ceulen, Roeland P.M.; Sommer, Anja; Vernooy, Kevin (2008). "Microembolism during Foam Sclerotherapy of Varicose Veins". New England Journal of Medicine 358 (14): 1525–6. doi:10.1056/NEJMc0707265. PMID 18385510.
12. Forlee, Martin V.; Grouden, Maria; Moore, Dermot J.; Shanik, Gregor (2006). "Stroke after varicose vein foam injection sclerotherapy". Journal of Vascular Surgery 43 (1): 162–4. doi:10.1016/j.jvs.2005.09.032. PMID 16414404.
13. Duffy, David M. (2012). "Sclerotherapy for Telangiectasia – The impact of small changes in vessel size on treatment outcomes" (PDF). Cosmetic Dermatology 25 (3): 126–33.
14. Treatment of Leg Veins. Procedures in Cosmetic Dermatology Series. Editors Murad Alam, Sirunya Silapunt. Second Edition Saunders Elsevier Inc. 2011
15. Schuller-Petrovic, S.; Pavlovic, M. D.; Schuller, S.; Schuller-Lukic, B.; Adamic, M. (2012). "Telangiectasias resistant to sclerotherapy are commonly connected to a perforating vessel". Phlebology 28 (6): 320–3. doi:10.1258/phleb.2012.012019. PMID 22865418.

External links

• "Varicose Veins and Spider Veins – FAQs". Womenshealth.gov. December 2005. Archived from the original on 6 Oct 2008.
• "Varicose veins and spider veins fact sheet". Womenshealth.gov. 2 June 2010.