What are the treatment options for telangiectasia?

Treatment Options for Telangiectasia

For cutaneous telangiectasias, sclerotherapy is the primary treatment for lower extremity lesions ≥2.5mm, while laser therapy is preferred for facial telangiectasias and smaller leg vessels <1mm. 1, 2, 3

Treatment Selection by Location and Vessel Size

Lower Extremity Telangiectasias

Sclerotherapy is the gold standard for leg telangiectasias and superficial venules, particularly for vessels measuring 2.5mm or larger in diameter. 4, 2, 5

• Sclerosing agents with established safety profiles include hypertonic saline (18-25%), polidocanol (Aethoxysklerol 0.25-1.0%), sodium tetradecyl sulfate (Sotradecol), and Sclerodex (dextrose/sodium chloride mixture). 2, 5

• Technical requirements for optimal outcomes: Use 30-gauge needles with 3-ml Luer-Lok syringes, employ 2-3X magnification for vessel visualization, thread the needle carefully into the vessel, and inject slowly with steady light pressure. 2

• Post-treatment compression is mandatory: Apply cotton balls, tape, and compression hosiery for 48 hours to maximize vessel closure and minimize complications. 2, 6

• **Vessels <2.0mm have significantly lower success rates** with sclerotherapy (16% primary patency at 3 months versus 76% for vessels >2.0mm), making alternative treatments more appropriate for these smaller vessels. 4

Facial Telangiectasias

Laser therapy is the preferred treatment modality for facial telangiectasias, offering multiple wavelength options tailored to vessel depth and patient skin type. 3

• 532-595nm lasers (pulsed-dye lasers and frequency-doubled Nd:YAG) effectively treat superficial telangiectasias while also addressing pigmentation and fine wrinkles, with newer cooling methods reducing pain and purpura. 3

• 1064nm Nd:YAG lasers penetrate more deeply to treat vessels up to 3-4mm in diameter and can safely treat all skin types (I-VI) with or without tan due to minimal melanin absorption. 3

• Intense pulsed light (IPL) with longer pulse durations represents an effective alternative for facial telangiectasias, particularly for vessels up to 1mm in diameter. 1, 6

• Sclerotherapy for facial vessels carries higher risk due to potential inadvertent injection into arterioles and should be reserved for larger blue telangiectasias when laser therapy is not suitable. 3

Special Clinical Contexts

Hereditary Hemorrhagic Telangiectasia (HHT)

For HHT-related epistaxis from nasal telangiectasias, oral tranexamic acid is now recommended as first-line systemic therapy for patients with mild to moderate bleeding not controlled by moisturizing topical therapies alone. 1

• Tranexamic acid reduces epistaxis duration by 17.3% and composite epistaxis scores by 54% without increasing thrombotic complications, based on randomized controlled trials of 118 and 22 patients respectively. 1

• Bevacizumab (systemic administration) demonstrates substantial efficacy with 85% of patients achieving epistaxis control in a 13-patient study and 56% reduction in epistaxis severity scores in a 34-patient study, though this represents off-label use. 1

• Thalidomide shows effectiveness in improving epistaxis frequency and severity with hemoglobin improvement, but persistent neuropathy limits long-term use (67 patients studied). 1

• Local ablative therapies including laser treatment, sclerotherapy, radiofrequency ablation, and electrosurgery remain options for HHT nasal telangiectasias, with laser and sclerotherapy having stronger evidence. 1

• Topical nasal bevacizumab and intranasal bevacizumab injections did not show significant benefit in prior trials, making systemic administration the preferred route when bevacizumab is used. 1

Radiation-Induced Rectal Telangiectasias

For radiation-induced rectal bleeding from telangiectasias, sucralfate enemas are more effective than corticosteroid enemas when topical treatment is indicated. 1

• Sucralfate enema preparation: Mix 2g sucralfate suspension with 30-50ml tap water, administer twice daily via soft Foley catheter, retain as long as possible, and initially roll through 360° to coat entire rectal surface. 1

• Endoscopic ablation options include argon plasma coagulation (serious complication rate 7-26%), laser ablation, and formalin application, though evidence for long-term outcomes is scanty. 1

• Hyperbaric oxygen treatment has support from one RCT and multiple case series for radiation-induced rectal telangiectasias. 1

• Treatment algorithm: (1) Flexible endoscopy to confirm diagnosis, (2) Optimize bowel function, (3) If bleeding doesn't affect quality of life, reassure and observe, (4) If bleeding affects quality of life, stop/reduce anticoagulants and consider sucralfate enemas, (5) Discuss definitive ablative treatment. 1

Rosacea-Associated Telangiectasias

For telangiectasias associated with rosacea, physical modalities (laser/IPL) are the primary treatment, as pharmaceutical agents target inflammatory features rather than vascular changes. 1

• Opinion is divided on monotherapy versus combination therapy for rosacea-associated telangiectasias at any severity level, unlike other rosacea features where severity guides treatment intensity. 1

• Ophthalmologists expect dermatologists to recognize telangiectasia as an ocular rosacea feature but do not expect treatment prior to referral except for mild symptoms managed with artificial tears. 1

Alternative and Adjunctive Modalities

Electrosurgery remains effective but is highly technique-dependent and has largely been superseded by laser therapy for most applications. 3, 7

Cryotherapy and CO2 laser represent historical treatment options with limited current use given superior alternatives. 7

Surgical phlebectomy can address reticular veins but is technically difficult and generally reserved for larger vessels not amenable to sclerotherapy or laser treatment. 3

Common Pitfalls and Contraindications

• Inadequate post-sclerotherapy compression leads to suboptimal vessel closure and increased recurrence rates; 48-hour compression is essential. 2, 6

• Treating vessels <2.5mm with sclerotherapy results in poor outcomes with only 16% patency at 3 months. 4

• Failure to investigate underlying venous insufficiency before treating leg telangiectasias may result in rapid recurrence; venous hemodynamic assessment is desirable when venous insufficiency is suspected. 6

• Sclerotherapy on facial vessels without proper technique risks inadvertent arteriolar injection with potential serious complications. 3

• Using topical corticosteroids for radiation-induced telangiectasias is ineffective since the damage is ischemic rather than inflammatory. 1