Which sclerotherapy solution works best?

No matter what sclerosant is used (hypertonic saline, sodium tetradecyl sulfate, polidocenol, or sodium morrhuate are the most common ones), it needs to get inside the spider vein to do its work! The smaller the spider vein, the harder it is to hit properly. Sclerotherapy, as you have found out, is highly operator-dependent, and less related to the solution used. All of the commercially-available sclerosants work well, but have different side effects, proper concentrations for uniform response, and different adherents among users. But all of them have one common denominator--they have to be skillfully and properly gotten into the vessel for it to "work." You have had poor results, I would submit, not because you have had a "wrong" solution (though to be truthful, it can be a partial factor), but because your injector simply missed the veins too often.

As someone who has performed sclerotherapy for 30 years, and taught laser surgery for over twenty, I can still unequivocally state that skillfully-performed sclerotherapy remains the "gold standard" for treatment of spider veins. Larger varicosities require other treatments, but it's the smaller ones that require the best technique and often are the biggest cosmetic concern. Lasers can work for some of the smallest spider veins, but usually at slightly higher risk of complications (blister, scar, pigmentation change, or inadequate result), and almost always at higher cost (It's the laser!).

Find your old sclerotherapist, or a new one with better skills. BTW, since you asked, I believe polidocanol is the best sclerosant, as it is the most pain-free, has the fewest side effects, and has great results when used in 1% concentrations with proper technique. I have use all of the others, so this is based on significant experience with these.

It can take up to 8 weeks to appreciate the results from your sclerotherapy treatment. Asclera and Sotradecol are the only 2 FDA approved agents for the treatment of small uncomplicated varicose veins of the legs.  Studies trying to compare the difference between these two agents and hypertonic saline have not shown a significant difference in effectiveness, but hypertonic saline tends to be more painful with injection and has a greater risk for ulcerations.  One must treat the underlying blue veins that feed the superficial spider veins, or treatment of the superficial spider veins will not be proven successful.  Results are dependent on the technique, compression, and sclerosant concentration used for the vein size being treated.

Sclerotherapy is usually done monthly for 3-6 treatments at a cost of $450 per session.  Usually Asclera is now the most recent solution FDA approved.  Whether by foam or by straight solution, both work very well.

Important considerations in sclerotherapy include the proper use of sclerosant solutions, but more importantly, the technique used for injection. Larger veins should be addressed prior to smaller end branches. As a fellow of the American College of Phlebology and a double board certified surgeon who is a Diplomate of the American Board of Phlebology and the American Board of Plastic Surgery, it is important for me to evaluate these venous patterns in a logical and comprehensive fashion prior to having treatment. Do not focus on the sclerosant as much as the surgical planning and knowledge of the treating physician.

Thank you for the question! Currently sclerotherapy is the treatment of choice when treating enlarged and bulging veins. In our practice, I use a sclerosing solution that causes the vein to shrink. Usually it takes only 1 to 2 sessions to achieve fading of the undesirable veins.  
An in-person exam with a board-certified plastic surgeon is the best way to assess your needs and obtain expert medical advice. Best of luck!

There are many techniques and solutions that are used for sclerotherapy. However, the best at the present time is a foam technique with Asclera. 

There are many types of sclerotherapy solutions and they fall into different categories.  Detergent solutions include sodium tetradecty, Asclera(polidocanol) and sodium morruhate.  These solutions are called detergents because they can be foamed like a soap.  Tetra decyl is stronger than Asclera but Asclera is the sclerosing agent of choice for many of us doing a lot of sclerotherapy.  Sodium morruhate is rarely used because of allergic side effects.  Saline is called an osmotic solution and was once the mainstay of sclerotherapy, but again, this too is now used much less often.  Asclera can be mixed in different concentrations for use in different size veins and can be used as either foam or liquid. Asclera is my sclerosing solution of choice for many reasons-it is painless to inject, it has very few side effects and it can be used as liquid or foam.

I have been injecting leg veins for almost 20 years and there certainly is a difference in solutions.  When I first started out the only option was saline solution injections.  These injections were extremely painful and not as effective as current solutions available.  Asclera is the newest and I believe the best sclerosing solution on the market today.  Yes, the experience of the injector is the most important.  Years ago many doctors touted lasers as the best treatments for spider veins.  Lasers only work on the exquisitely small veins that are too small to be injected.  It is best to be injected several times, approximately one month apart, with Asclera.  If there are tiny tribuaries that remain, these can then be "touched up" with the V-Beam Laser.  It is most important to find an experienced Cosmetic Dermatologist for this and every procedure.

More important than the solution is the injector.  Most of the solutions that physicians use for sclerotherapy work and work fairly well. This is a procedure which is highly operator dependent.  Small vessels such spiders can sometimes be difficult to get into and if you are not experienced it can be troublesome.  Having injected veins for over twenty years I have not seen significant differences in the effectiveness of the solutions but their are some regarding their degree of staining induced  and pain.  Recently the FDA approved a new solution polidocanol, trade name Asclera.  It's main advantage over hypertonic saline is that it is not painful.  Although there are some risks of allergic reaction with polidocano, l it seems to be very small and has become a favorite for many sclerotherapist.

In my office we offer a variety of solutions depending upon the size of the vessel. We also use a yag laser. Results are generally good, but you must have several treatments and it takes 6-8 weeks for the end results!