Jornal Vascular Brasileiro
https://jvascbras.org/article/doi/10.1590/1677-5449.202501082
Jornal Vascular Brasileiro
Innovation

Evaluation of a clinical score to predict post-sclerotherapy hyperpigmentation compared with the Skin Hyperpigmentation Index: a prospective Skin Code study

Avaliação de um escore clínico para predição de hiperpigmentação pós-escleroterapia em comparação com o Índice de Hiperpigmentação Cutânea: estudo prospectivo Skin Code

Renata Camila Barros Rodrigues; Samantha Neves; Eduardo Ramacciotti; Viviane Santana da Silva; Roberto Augusto Caffaro; Flávia Magalhães Silveira Magella Oliveira; Alexandre Fioranelli; Rebeca Higino Becker

http://dx.doi.org/10.1590/1677-5449.202501082 J Vasc Bras, vol.25, e20250108, 2026
PDF
Downloads: 0
Views: 9

Abstract

Post-sclerotherapy hyperpigmentation (PSH) is a common complication following sclerotherapy for telangiectasias and reticular veins. However, tools for pre-procedural prediction of PSH are limited, making pre-treatment identification of patients at greater risk a challenge. This research aimed to evaluate a clinical scoring system (Skin Code Score) designed to estimate the individual risk of PSH. A prospective, single-center, single-arm study was conducted. Adult female patients with telangiectasias and reticular veins were treated and evaluated for pigmentation risk using the Skin Code Score (range, 2-12 points). Hyperpigmentation was assessed at baseline and on day 30 by in-person evaluation performed by one vascular surgeon, complemented by photographic analysis conducted independently by two other vascular surgeons and one dermatologist. Skin Hyperpigmentation Index (SHI) measurements were used for objective correlation with the Skin Code Score. The Skin Code Score showed strong interobserver agreement and reproducibility (κ ≥ 0.85). Diagnostic accuracy ranged from 82.8% to 94.7% among evaluators. A score of 12 predicted PSH in up to 99.8% of cases, while a score of 8 indicated a probability of approximately 76%. The study was limited by a small sample size and its single-center design; a proportion of the assessments were conducted by photographic analysis. It is concluded that the Skin Code Score is a simple and reproducible tool for predicting PSH and could assist clinicians with pre-procedural risk stratification, patient counseling, and clinical decision-making.

Keywords

post-inflammatory hyperpigmentation; telangiectasias; reticular veins; sclerotherapy; skin

Resumo

A hiperpigmentação pós-escleroterapia (HPE) é uma complicação comum após a escleroterapia de telangiectasias e veias reticulares. No entanto, os instrumentos para predição pré-procedimento da HPE são limitados, tornando desafiadora a identificação de pacientes com maior risco antes do tratamento. A pesquisa objetivou avaliar um sistema de escore clínico (Skin Code Score) desenvolvido para estimar o risco individual de HPE. Foi realizado um estudo prospectivo, unicêntrico e de braço único. Pacientes adultas do sexo feminino com telangiectasias e veias reticulares foram tratadas e avaliadas quanto ao risco de pigmentação utilizando o Skin Code Score (intervalo de 2 a 12 pontos). A hiperpigmentação foi avaliada no 1° dia e no 30º dia por meio de exame presencial realizado por um cirurgião vascular, complementado por análise fotográfica conduzida de forma independente por dois cirurgiões vasculares e um dermatologista. Medidas do Índice de Hiperpigmentação Cutânea (Skin Hyperpigmentation Index – SHI) foram utilizadas para correlação objetiva com o Skin Code Score. O Skin Code Score apresentou forte concordância interobservador e reprodutibilidade (κ ≥ 0,85). A acurácia diagnóstica variou de 82,8% a 94,7% entre os avaliadores. Um escore de 12 previu HPE em até 99,8% dos casos, enquanto um escore de 8 indicou probabilidade aproximada de 76%. O estudo foi limitado pelo pequeno tamanho amostral e pelo delineamento unicêntrico; parte das avaliações foi realizada por meio de análise fotográfica. Conclui-se que o Skin Code Score é uma ferramenta simples e reprodutível para a predição de HPE e pode auxiliar os médicos na estratificação de risco pré-procedimento, no aconselhamento dos pacientes e na tomada de decisão clínica.

Palavras-chave

hiperpigmentação pós-escleroterapia; telangiectasias; veias reticulares; escleroterapia; pele

References

1 Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3(7):20-31. PMid:20725554.

2 Bossart S, Daneluzzi C, Cazzaniga S, et al. Skin hyperpigmentation after sclerotherapy with polidocanol: a systematic review. J Eur Acad Dermatol Venereol. 2023;37(2):274-83. https://doi.org/10.1111/jdv.18639. PMid:36196455.

3 Heidemeyer K, Cazzaniga S, Feldmeyer L, et al. Skin hyperpigmentation index in melasma: a complementary method to classic scoring systems. J Cosmet Dermatol. 2023;22(12):3405-12. https://doi.org/10.1111/jocd.15866. PMid:37349912.

4 Nakano LC, Cacione DG, Baptista-Silva JC, Flumignan RL. Treatment for telangiectasias and reticular veins. Cochrane Database Syst Rev. 2021;10(10):CD012723. PMid:34637138.

5 Eklof B, Perrin M, Delis KT, Rutherford RB, Gloviczki P. Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg. 2009;49(2):498-501. https://doi.org/10.1016/j.jvs.2008.09.014. PMid:19216970.

6 Eklöf B, Rutherford RB, Bergan JJ, et al. Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg. 2004;40(6):1248-52. https://doi.org/10.1016/j.jvs.2004.09.027. PMid:15622385.

7 Wong M, Parsi K, Myers K, et al. Sclerotherapy of lower limb veins: Indications, contraindications and treatment strategies to prevent complications: a consensus document of the International Union of Phlebology-2023. Phlebology. 2023;38(4):205-58. https://doi.org/10.1177/02683555231151350. PMid:36916540.

8 Bossart S, Willenberg T, Ramelet AA, Cazzaniga S, Hunger RE, Seyed Jafari SM. The skin hyperpigmentation index: An objective method of measuring the intensity of hyperpigmentation after sclerotherapy. Phlebology. Phlebology. 2020;35(10):833-5. https://doi.org/10.1177/0268355520941359. PMid:32715908.

9 Goldman MP. Complications and adverse sequelae of sclerotherapy. In: Bergan JJ, editor. The vein book. Burlington: Academic Press; 2007. p. 139-55. https://doi.org/10.1016/B978-012369515-4/50018-1.

10 Peterson JD, Goldman MP, Weiss RA, et al. Treatment of reticular and telangiectatic leg veins: double-blind, prospective comparative trial of polidocanol and hypertonic saline. Dermatol Surg. 2012;38(8):1322-30. https://doi.org/10.1111/j.1524-4725.2012.02422.x. PMid:22620717.

11 Bertanha M, Sobreira ML, Pinheiro Lucio Filho CE, et al. Polidocanol versus hypertonic glucose for sclerotherapy treatment of reticular veins of the lower limbs: study protocol for a randomized controlled trial. Trials. 2014;15(1):497. https://doi.org/10.1186/1745-6215-15-497. PMid:25527165.

12 Bossart S, Cazzaniga S, Willenberg T, et al. Skin hyperpigmentation index: a new practical method for unbiased automated quantification of skin hyperpigmentation. J Eur Acad Dermatol Venereol. 2020;34(7):e334-6. https://doi.org/10.1111/jdv.16312. PMid:32103550.

13 Bossart S, Cazzaniga S, Willenberg T, et al. Reliability assessment and validation of the skin hyperpigmentation index compared to the physician global assessment score. Dermatology. 2022;238(4):688-91. https://doi.org/10.1159/000520753. PMid:34969031.

14 Zhang L, Ng K, Pham JP, et al. Pigmentation of lower limbs: Contribution of haemosiderin and melanin in chronic venous insufficiency and related disorders. Phlebology. 2023;38(10):657-67. https://doi.org/10.1177/02683555231196702. PMid:37642293.

15 Caggiati A, Rosi C, Franceschini M, Innocenzi D. The nature of skin pigmentations in chronic venous insufficiency: a preliminary report. Eur J Vasc Endovasc Surg. 2008;35(1):111-8. https://doi.org/10.1016/j.ejvs.2007.08.007. PMid:17920308.

16 Azar J, Rao A, Oropallo A. Chronic venous insufficiency: a comprehensive review of management. J Wound Care. 2022;31(6):510-9. https://doi.org/10.12968/jowc.2022.31.6.510. PMid:35678787.

17 Bertanha M, Jaldin RG, Moura R, et al. Sclerotherapy for reticular veins in the lower limbs: a triple-blind randomized clinical trial. JAMA Dermatol. 2017;153(12):1249-55. https://doi.org/10.1001/jamadermatol.2017.3426. PMid:28973414.

18 Ávila Oliveira R, Riera R, Vasconcelos V, Baptista-Silva JC. Injection sclerotherapy for varicose veins. Cochrane Database Syst Rev. 2021;12(12):CD001732. PMid:34883526.

19 Mosca S, Morrone A. Human skin pigmentation: from a biological feature to a social determinant. Healthcare (Basel). 2023;11(14):2091. https://doi.org/10.3390/healthcare11142091. PMid:37510532.

20 Mruthyunjayappa S, Hemalata M, Gopal MG. A study of spectrum of histopathological features in patients presenting with hyperpigmented skin lesions. Arch Med Health Sci. 2016;4(2):189. https://doi.org/10.4103/2321-4848.196195.

21 Leal-Silva H. Predicting the risk of postinflammatory hyperpigmentation: The palmar creases pigmentation scale. J Cosmet Dermatol. 2021;20(4):1263-70. https://doi.org/10.1111/jocd.13968. PMid:33533144.

22 Bossart S, Willenberg T, Ramelet AA, Cazzaniga S, Hunger RE, Seyed Jafari SM. The skin hyperpigmentation index: an objective method of measuring the intensity of hyperpigmentation after sclerotherapy. Phlebology. 2020;35(10):833-5. https://doi.org/10.1177/0268355520941359. PMid:32715908.

23 Nordlund JJ. Postinflammatory hyperpigmentation. Dermatol Clin. 1988;6(2):185-92. https://doi.org/10.1016/S0733-8635(18)30665-X. PMid:2454174.

24 Kikuchi R, Yoshida WB, Kakkos SK, et al. Brazilian guidelines on chronic venous disease of the Brazilian Society of Angiology and Vascular Surgery. J Vasc Bras. 2023;22:e20230064. https://doi.org/10.1590/1677-5449.202300642. PMid:38021274.

25 Nautiyal A, Wairkar S. Management of hyperpigmentation: Current treatments and emerging therapies. Pigment Cell Melanoma Res. 2021;34(6):1000-14. https://doi.org/10.1111/pcmr.12986. PMid:33998768.
 

Submitted date:
11/05/2025

Accepted date:
08/09/2026

Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)"> Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)">
6ab6b582a9539546335360e7 jvb Articles
Links & Downloads
1677-7301 (Electronic)
J Vasc Bras ©2026 All rights reserved for this website content. Articles follow their own licenses.

J Vasc Bras

Share this page
Page Sections