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Thrombophlebitis Treatment & Management

  • Author: Melanie D Palm, MD, MBA, FAAD; Chief Editor: Dirk M Elston, MD  more...
 
Updated: Sep 24, 2014
 

Medical Care

The location of the thrombosis directs the treatment.

If progression to DVT is suspected or proven, adequate anticoagulation is imperative to prevent PE and other possible long-term complications of DVT.

Low molecular weight heparin (LMWH) or fondaparinux is considered the treatment of choice for SVT, although the appropriate length of treatment is unclear. Forty-five days of treatment is recommended by the American College of Chest Physicians.[108] Topical treatment alone is not adequate.[109] The use of LMWH in patients with SVT may decrease perivascular inflammation. LMWH limits neutrophil extravasation.[110] Thus, LMWH has anti-inflammatory properties in addition to anticoagulant properties. High doses of unfractionated heparin are shown to be more effective in preventing thromboembolic combinations than prophylactic doses.[111]

LMWH and nonsteroidal anti-inflammatory drugs (NSAIDs) both were shown to decrease the incidence of thrombophlebitis spread by approximately 70% in a meta-analysis of 24 studies and nearly 2500 patients.[109] In a small study of 72 patients, LMWH (dalteparin) was found to be superior to NSAIDs (ibuprofen) in preventing extension of DVT.[112]

Alternatively, superficial relapsing superficial venous thrombophlebitis may be treated with subcutaneously placed fondaparinux or oral rivaroxaban.[113] A large review of 30 studies involving 6507 participants with SVT of the legs found a 6-week course of fondaparinux to be a valid therapeutic option.[114]

Patients with extensive involvement of leg varices should receive anticoagulants. This treatment is particularly important if the proximal part of the SFJ is involved. In addition to propagation of the thrombus through the SFJ, 11-40% of patients with SVT at the SFJ have evidence of concurrent DVT.[97, 98, 115, 116] In these patients, anticoagulation for 6 months resolved the DVT or SVT and prevented PE. This success occurred despite duplex ultrasonographic evidence of SVT progression to DVT in 2 of 20 patients.[115]

The role of oral or topical NSAIDs and compression therapy is unclear, as data are insufficient to draw meaningful conclusions.[93] Aspirin or other NSAIDs may be helpful in limiting both inflammation and pain. NSAIDs are associated with lower rates of SVT progression compared with placebo.[93] Adequate graduated compression should be maintained, and the patient should ambulate frequently until the pain and inflammation resolve. In addition to adequate graduated compression, drainage of the thrombi after their liquefaction (approximately 2 wk after onset of the lesion) hastens the otherwise slow, painful resorption process.[117]

Other treatment modalities have been tried but lack conclusive results from large clinical trials. Pycnogenol (an oral antithrombotic agent) has been found to decrease the number of thrombotic events during long-haul flights.[118] Essaven gel improved the signs and symptoms of SVT of the arms.[119] Diclofenac gel and Exhirud ointment are no longer used or are used very infrequently as topical treatments.[109]

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Surgical Care

Emergency surgical interventions may be effective in preventing complications of SVT.[120] Surgical interventions are associated with the lowest incidence of extension of the thrombus and allow the patient to return to work faster than nonsurgical modalities.[118]

Under the appropriate circumstances, incision and drainage of the clot should be attempted to alleviate pain.

If the thrombosis extends into the deep venous system, ligation and stripping of the affected vein should be considered.

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Consultations

SVT can usually be treated conservatively, as described above, unless extension into the deep venous system is imminent.

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Activity

Patients should be encouraged to be ambulatory.

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Contributor Information and Disclosures
Author

Melanie D Palm, MD, MBA, FAAD Director, Art of Skin MD; Assistant Volunteer Clinical Professor, University of California, San Diego, School of Medicine; Affiliate Physician, Scripps Encinitas Memorial Hospital

Melanie D Palm, MD, MBA, FAAD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, Women's Dermatologic Society

Disclosure: Nothing to disclose.

Coauthor(s)

Zoltan Trizna, MD, PhD Private Practice

Zoltan Trizna, MD, PhD is a member of the following medical societies: Texas Medical Association

Disclosure: Nothing to disclose.

Mitchel P Goldman, MD Voluntary Clinical Professor of Dermatology, University of California, San Diego, Medical Center; Dermatologist, Cosmetic Laser Dermatology

Mitchel P Goldman, MD is a member of the following medical societies: American College of Phlebology, Aerospace Medical Association, American Society of Lipo-Suction Surgery, Phi Beta Kappa, Dermatology Foundation, San Diego County Medical Society, American Academy of Cosmetic Surgery, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for Laser Medicine and Surgery, California Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Julia R Nunley, MD Professor, Program Director, Dermatology Residency, Department of Dermatology, Virginia Commonwealth University Medical Center

Julia R Nunley, MD is a member of the following medical societies: American Academy of Dermatology, American College of Physicians, American Society of Nephrology, International Society of Nephrology, Medical Dermatology Society, Medical Society of Virginia, National Kidney Foundation, Phi Beta Kappa, Women's Dermatologic Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Board of Dermatology<br/>Co-Editor for the text Dermatological Manifestations of Kidney Disease .

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Carrie L Kovarik, MD Assistant Professor of Dermatology, Dermatopathology, and Infectious Diseases, University of Pennsylvania School of Medicine

Carrie L Kovarik, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

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