Transdermal laser associated with sclerotherapy in tumescent anesthesia for the treatment of telangiectatic matting

Abstract

Telangiectatic matting refers to the proliferation of fine vessels with less than 0.2 mm diameter, often occurring as a secondary effect of sclerotherapy using hypertonic glucose or foam. It is one of the most aesthetically distressing and challenging complications of reticular vein and telangiectasia treatments, with spontaneous resolution reported between 3 to 12 months. The 1064-nm Nd:YAG transdermal laser holds a level 2b recommendation for treating matting, although various strategies have been explored due to the complexity of this condition. This case report presents the successful management of persistent matting using transdermal laser associated with sclerotherapy and tumescent anesthesia.

Chronic venous disorders affect the lower limb venous system and are categorized based on clinical, etiological, anatomical, and pathophysiological criteria according to the CEAP classification.¹ Stage C1 includes telangiectasias and reticular veins,² which, together with stage C2, represent the most common manifestations.¹ Sclerotherapy remains the standard treatment for these conditions.^1,3

The 1064-nm Nd:YAG transdermal laser is recognized for treating telangiectasias⁴ and more resistant lesions, with a level 2b recommendation.³ Combining laser with liquid or foam sclerotherapy seems to enhance treatment outcomes; however, further research is required to reinforce this evidence.^3,5

Potential complications of telangiectasia treatment include treatment failure, hyperpigmentation, and matting.^6,7 Telangiectatic matting is considered the most aesthetically concerning complication, characterized by the proliferation of fine vessels less than 0.2 mm in diameter following sclerotherapy with glucose or foam.^8,9 It can be transient, resolving within 12 months, or permanent, occurring in up to 10% of cases.^2,10,11

Managing matting requires technical expertise and careful patient counseling, as the appearance of new veins after therapy can cause significant distress. This report describes the successful treatment of permanent matting using a combination of transdermal laser, sclerotherapy, and tumescent anesthesia. The patient provided written consent to the publication of this case.

Case report

A 33-year-old female, Fitzpatrick skin type II, nonsmoker, physically active, with no medication or food allergies, and a history of oral contraceptive use for 9 years, allergic rhinitis, and rosacea. She previously sought medical evaluation for aesthetic concerns regarding combined telangiectasias on the posterior and lateral left thigh (Fig 1).

Fig 1.

Telangiectasias and reticular veins on the lateral and posterior aspects of the left thigh (images provided by the patient).

According to the patient, initial treatment with polidocanol foam sclerotherapy and transdermal laser showed no improvement, and a second session was performed 30 days later. Postprocedure, the patient developed hyperemia, edema, intense local pain (Fig 2, A), and subsequent matting (Fig 2, B and C).

Fig 2.

(A) Hyperemia and edema post-treatment with dense polidocanol foam and transdermal laser (7 days postprocedure). (B) Telangiectatic matting noted by the patient approximately 3 weeks post-treatment, after regression of the acute inflammatory process. (C) Matting at 5 months after onset (images provided by the patient).

Conservative management was maintained for 3 months, anticipating spontaneous regression of the telangiectatic cloud. After no improvement, two additional foam sclerotherapy sessions were performed, but matting persisted. Afterward, oral supplementation with pycnogenol 100 mg, Polypodium leucotomos 200 mg, vitamin C 100 mg, and tranexamic acid 250 mg for 3 months produced no effect. The patient then independently took diosmin and hesperidin 450/50 mg twice daily for approximately 7 months.

Fifteen months after onset, following informed consent and photodocumentation (Fig 3, A and B), retreatment was pursued. Doppler ultrasound ruled out saphenous or perforator reflux. Ectoscopic examination revealed fine telangiectasias and, with a phleboscope, reticular veins on the lateral left thigh were identified (Fig 3, C). Pretreatment preparation included diosmin/hesperidin 900/100 mg daily and pycnogenol 200 mg/day, alongside hydration for 15 days.

Fig 3.

(A and B) Pre-treatment documentation 15 months after matting onset. (C) Identification of reticular vein network.

Treatment was initiated with Nd:YAG 1064-nm transdermal laser and 75% glucose sclerotherapy (1.5 mL total volume). Tumescent solution of 250 mL saline with 5 mL 2% buffered lidocaine was infused into the treated areas immediately after sclerotherapy to produce an “orange peel” skin appearance. The goal was to achieve localized tissue compression. Elastic stockings (20-30 mmHg) were applied for 24 hours postprocedure, then daily for 2 weeks, with removal overnight.

At the 60-day follow-up, marked improvement was observed, and the same protocol was applied to the remaining telangiectasias. Diosmin/hesperidin and pycnogenol were maintained for an additional 45 days. At final evaluation (Fig 4, A-D), the patient was satisfied, and no further intervention was deemed necessary.

Fig 4.

Post-treatment results 3 months after combined therapy with transdermal laser + liquid sclerotherapy + tumescence. (A and B) Orthostatic position. (C and D) Supine position.

Discussion

Telangiectatic matting refers to the emergence of new, finer vessels in areas previously treated with sclerotherapy. This complication occurs in up to 24% of cases^9,12,13 and may be transient—with spontaneous resolution within 12 months,^2,10—or permanent.

Although the etiology is still uncertain, matting is believed to involve both inflammatory and hemodynamic responses. Factors such as untreated reflux, excessive sclerosant concentration or volume, and underlying reticular veins contribute to its development. Treating telangiectasias without considering the underlying disease or hypoxia-induced neovascularization may be the cause of the formation of the telangiectatic cloud.⁶

Screening for proximal or perforating reflux in the region of the telangiectatic entanglement should be part of pretreatment assessment. Therefore, proper evaluation using Doppler ultrasound and transillumination (phleboscopy or near-infrared vein finder) is essential.

Matting’s appearance after high concentrations or large volumes of sclerosant⁸ is likely due to inflammation or excessive venous obstruction with subsequent angiogenesis.¹³ Therefore, it is recommended to use the lowest possible concentration of sclerosant, with small quantities and low infusion pressure.

Other risk factors should be considered during the patient’s anamnesis to help define the etiology of the complication or even to align expectations for resolving the case. Matting is more common in women and may relate to family history of telangiectasias, obesity, and exogenous estrogen use¹⁴ (oral contraceptive pill or hormone replacement therapy). Recent studies observed an association between the development of matting and bleeding disorders, such as epistaxis and frequent bruising, in addition to hypersensitivity disorders, including eczema, rhinitis, or bronchial asthma.¹⁵

Our patient had rosacea, allergic rhinitis, and prolonged oral contraceptive use—suggesting hormonal and inflammatory predisposition. Although polidocanol foam concentration and volume from previous treatments were unknown, intense postprocedural inflammation raised suspicion of high-volume-induced panniculitis.

Recent publications advocate topical medications in attempt to reverse matting, but there is still no robust evidence.^1,2 In our clinical practice, difficulties accessing such medications made it impossible to use them as a treatment attempt.

Evidence supporting oral treatment for matting is limited. Previous use of P. leucotomos, vitamin C, and tranexamic acid in this case appears to rely on their antioxidant activity and potential to mitigate postinflammatory hyperpigmentation16, 17, 18

Diosmin and hesperidin are well-known for improving venous tone, microcirculation, and reducing edema.³ Pycnogenol aims to help prevent hyperpigmentation.¹⁹ In our therapeutic strategy, these agents were selected to modulate inflammation and potentially improve aesthetic outcomes.

Given the lesion’s refractoriness and intense inflammatory response to polidocanol, we adopted a low-volume, low-concentration approach, incorporating transdermal laser to reduce the required sclerotherapy volume. Because foam may induce more matting than liquid sclerosing agents,^3,6 hypertonic glucose sclerotherapy was performed.

Transdermal laser was applied in dual-pulse mode to reticular veins and single-pulse mode to telangiectasias, followed by sclerotherapy of the reticular veins with 1 mL of 75% glucose. Residual telangiectasias unresponsive to a second laser pass were treated with 0.5 mL of 75% glucose to ensure vessel ablation while minimizing damage to the surrounding skin.

Tumescent anesthesia was then administered. Although further studies are needed, the START technique (Sclerotherapy in Tumescent Anesthesia of Reticular Veins and Telangiectasias)²⁰ appears to enhance outcomes by reducing perivascular inflammation and promoting tissue compression.

Elastic stockings complement treatment by decreasing postsclerotherapy thrombi formation and hyperpigmentation.²¹ However, compression at the thigh is often insufficient as it does not directly reduce the lumen of telangiectasias. Its effect during ambulation promotes a massage-like action, which may exert anti-inflammatory effects in the perivenous space.

Because elastic stockings exert only 41% to 74% of the ankle-level compression at the thigh, pressures above 80 mmHg would be necessary to fully collapse telangiectasias in standing position.²¹ Tumescence following sclerotherapy can be a valuable alternative, as it provides sustained subcutaneous pressure, fulfilling the compressive role often insufficiently achieved by elastocompression alone—especially in the thigh region.

Tumescence compresses subcutaneous tissues for several hours due to its high intratissue pressure.²⁰ The combined approach aligns with the “Triple E” strategy: effective sclerosant concentration, effective vasospasm, and effective compression.⁴

This case demonstrates that a multimodal approach including tumescent anesthesia can be effective and safe for managing refractory telangiectasias or matting.

Funding

None.

Disclosures

None.