Many patients tell their doctors they are tired and they have no energy. Their legs itch. Their ankles are swollen. While many patients are concerned about the aesthetic implications of their veins, the problem can have very serious medical implications. Discoloration of the skin and ulcers of the legs are a manifestation of very advanced disease and are the result of blood leaking into the surrounding tissue. If you have continuous pain in one or both legs, a deep vein thrombosis (blood clot) needs to be considered and you should see a doctor immediately. Because of these serious complications that can arise from varicose or spider veins, patients must be treated by a licensed physician. You don’t want to think you are “cured” of your vein problem, only to find them again later. A specialist should literally look underneath the skin to find the cause of the spider/varicose veins and then will properly assess your individual situation and provide you with the appropriate treatment options. What causes spider/varicose veins? The build-up of pressure in the veins is the usual culprit. The main reason is heredity. If you are overweight, you may be more susceptible to spider/varicose veins. Other causes include hormonal changes, such as puberty, birth control pills, menopause, receiving an injury to the area, standing or sitting for a prolonged time and hormone replacement therapy. Simply getting older is another sign. The methods used by many physicians and nurses are just not capable of treating the underlying damaged reticular veins that are the real source of the spider veins. A saline injection or laser is not sufficient. This almost always requires specialized equipment that can see under the patient’s skin. Unfortunately, many times, other treatments are only temporary or make the patient’s problems much worse. The treatments usually involve a series of tiny injections, and the number of treatments is determined by the quantity of veins, since there is a limit to the quantity of sclerosant that can be given. Even if a patient is needlephobic, we find they still tolerate the painless procedure very well. A foaming technique with specialized sclerosants has been shown to be far more effective than sclerosants alone. Although many patients want only certain areas treated, especially the ankles, this is not prudent. Ankles should be treated last and performed by someone with expertise in this area because of the dangers associated with the unique vascular supply. Since patients are unaware of the underlying damaged reticulars, these need to be shown to the patient, and a proximal to distal method should be employed. Patients tend to forget how bad their legs looked before the procedure, so it is a good idea to take before and after pictures. Once you show them the old photos, they are completely blown away by the dramatic change in their appearance. Most patients may return to their normal activities immediately. I always tell my women patients, “Yes, you can even go shopping after your procedure is done that same day.” They always love to hear that! Patients can continue to participate in their regular exercise activity, except for high impact exercise (i.e., running on hard surfaces). Occasionally, a patient will develop a tender lump on the treated vein. This is usually due to trapped blood because of partial closing and is not a blood clot. If not treated within a few weeks by aspiration, hyperpigmentation will typically develop, which is due to the heme (iron) in the blood extravasating into the tissues and staining them. Most time, this will resolve on its own, but can take up to a year if not treated early. Other complications are rare and should be discussed with the patient before every treatment. Dr. Sidney Kass is the founder of Kass Clinic's based in St. Louis Park, MN.