An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology
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Microsclerotherapy Complications An Aesthetic Complications Expert Group Consensus Paper E 2 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY April 2017 • Volume 10 • Number 4 The following precautions are advised: • Advise patients to sit after treatment before standing, as syncope may be one of the causes. • Lying beneath bright lights during treatments may induce a migraine in known sufferers and the author advocates supplying these patients with sunglasses to wear during treatment. Ulceration/Infection 3,4,5 Ulceration and infection are rare following treatment and are also dependent on injection technique. Ulcerations range from a tiny scab to a large ulcer. They are very likely to occur if you inject into an artery. The author has twice inadvertently injected into an artery. The first was many years ago, before the use of ultrasound- guided techniques, when injecting a calf perforator and immediately saw the skin blanch. The patient developed a 10p size ulcer as a result. The second instance was upon injecting a prominent flare on a forehead. There are a number of possible causes of smaller ulcerations: • An accidental injection into a small arteriovenous fistula when injecting a small vessel. This is probably unavoidable, but if you see your sclerosant spreading rapidly through a flare, stop injecting immediately. The author's view is that if your treatment does not clear a patch the first time, your patient may be disappointed, but not cross. It may well be that there are small arterioles in superficial flares. If you are injecting a vessel you cannot visualize, use a small butterfly or an STD injection kit and view the rate of back flow into the tubing. • Sclerosant concentration. Too potent a sclerosant is probably another cause and it is safer to use very dilute sclerosants. If you do not obtain good clearance, rather than increase the strength, it is better to inject a larger volume on the second occasion. Remember that a sclerosant can be diluted. Check with the manufacturer for accurate information on dilution. The author dilutes sodium tetradecyl sulphate with water for injection and polidocanol with normal saline. Also be very careful to remember that sodium tetradecyl sulphate and polidocanol have very different potencies. Sodium tetradecyl sulphate is about three times as potent strength for strength as polidocanol. • Extravascular injection. Avoidance of this complication is down to good technique and adequate magnification. If you see any perivascular leakage stop injecting immediately. Some practitioners suggest that perivascular injections of a sclerosant can be effective, this is at their peril according to the author. It is better to prevent these complications rather than to treat them; however, there may be a role for the use of anti- i nflammatory gels (e.g., diclofenac, ibuprofen, or piroxicam) in their managment. Be cautious with certain skin types, in particular very pale skin and blue eyes, and most of all Asian skin, which can be very sensitive. Infections are extremely rare although if they do occur, please refer to the ACE Group guideline on Acute Infection. Matting Occasionally, when injecting patients, you will see the development of "matting" at the site of an injection, surgical scar, or catheter portal. It can be quite a distressing complication for a patient, but is treatable. The cause of matting is uncertain, but it is the author's opinion that it is either an inflammatory response or the development of a small arteriovenous fistula. Matting can be treated by identifying a local reticular vein with ultrasound and injecting a small quantity of foam. Good compression must be applied following the injection. The application of an anti- inflammatory gel can also help. Skin Staining/Pigmentation/Blood Entrapment Hemosiderin skin staining may occur after microsclerotherapy. The risk of this varies with skin type and pre-treatment expectation counselling is very important. Those with very fair skin, pale blue eyes, and Asian skin are all more at risk of skin marking after treatment. Immediate compression with stretchy Velcro tourniquets during treatment followed by post-treatment compression with a combination of a fixed stretch cohesive bandage and class II compression hosiery can reduce or prevent marking. The author recommends an average of five days post-treatment compression, but this varies depending on a number of factors. After microsclerotherapy treatment, small quantities of trapped blood can be seen in the treated vessels. Careful aspiration of this blood, with the tip of a 25g needle, is very important to reduce marking and speed up resolution. It usually takes trapped blood about 10 days to hemolyze, therefore wait at least 12 to 14 days before carrying out this procedure. It is virtually painless as it is very superficial and will significantly speed up resolution.