What is lymphedema?
Lymphedema is an abnormal collection of protein rich fluid beneath the skin resulting in chronic inflammation, fibrotic tissue, and increased production of adipose tissue depending on the limb/region affected. Lymphedema can effect one or both arms, one or both legs, head and neck, trunk, or a combination of limbs/regions.
There are two types of lymphedema primary and secondary. Primary or congenital lymphedema is a defect to the lymphatic system the patient is born with and often goes undiagnosed in majority of cases. Secondary lymphedema is more commonly diagnosed. The most common cause of secondary lymphedema is treatment for cancer, predominantly breast cancer. However, cancer of any kind can be a direct link to lymphedema. Secondary lymphedema can also be caused by other diagnoses such as inflammatory diagnoses, congestive heart failure, cellulitis, trauma, venous disease, etc.
Signs and Symptoms of Lymphedema
Generally, lymphedema begins gradually and worsens over time. Many patients are unaware of their lymphedema diagnosis until swelling becomes significant. Patients may report they have had had swelling that gradually worsens over the past 6 months when in reality their clinical presentation reveal the swelling has been present for much longer. Lymphedema is a chronic progressive disease. If not treated lymphedema will lead to skin changes and extreme swelling. Common signs & symptoms include:
- Pitting: is when you press into the swollen area and your finger print remains and there are varying stages of pitting. The depth of pitting and how long the indentation remains is indicative of how much fluid is present. As lymphedema worsens, skin will no longer pit due to presence of fibrosis and adipose tissue deposits.
- Discomfort (Pain): pain is subjective. Patients commonly report heaviness, achiness, and tension in their skin. Patients may report pain but this is rare in lymphedema. Pain may indicate a disease in conjunction with lymphedema such as cellulitis, malignancy, neurological issues, or orthopedic issues not lymphedema related.
- Increased Risk of Infection: Lymphedema is closely related to the immune and circulatory system. Due to stagnant fluid, this can increase the risk of infection called cellulitis and erysipelas. Both need immediate medical attention.
- Swelling: swelling can present in any part of the limb initially and gradually worsen, but most likely will begin toward the end of limb such as the hand or foot. Patients with upper extremity edema may first notice swelling in the forearm or hand. In lower extremity patients, the first sign may be that their shoes and socks become tight and potentially leave an indentation at the ankle or top of the foot. Patients may also notice the contours of their limb may be lost.
- Asymmetrical Presentation: only presents in one limb or region of the body. It can potentially present in both legs and rarely affects both arms.
- Tissue Changes: can appear in later stages of Lymphedema and is indicated with significant skin changes. Generally seen in lower extremities, rarely in upper extremities.
- Hyperkeratosis (overgrown later of skin, thicken skin)
- Lympho-cutaneous cysts (small bumps on the affected area of skin)
- Papillomatoses (papule that are fibrotic or hard)
- Erythema (chronic redness)
- Adipose (fat) tissue changes
How is lymphedema treated?
The gold standard treatment for lymphedema is Complete Decongestive Therapy.
Complete Decongestive Therapy consists of four components: Manual Lymphatic Drainage, Compression Therapy, Exercise, and Skin Care.
- Manual Lymphatic Drainage (MLD): a gentle massage to stimulate lymphatic system and encourage reabsorption of protein rich fluid. MLD is used to re-route fluid from affect region to region with healthy lymphatic activity.
- Compression Therapy: bandaging with layers of short stretch compression bandages. Prevents re-accumulation of fluid and improves efficiency of muscle pumps. Compression alone does not adequately treat lymphedema.
- Exercise: should be performed in conjunction with compression for best results. Exercise creates muscle pump, which facilitates lymphatic and venous return. A home exercise program with be customized to each patient.
- Skin Care: good skin and nail care is imperative to maintain the integrity of the skin and immune system to avoid infections.
- Self-Care: patient will be instructed in self-care such as skin care, how to apply bandages/garments, exercises, self-manual lymphatic drainage massage, and follow visits to maintain decongestion of fluid.