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Capital Region Vein and Laser Centre | Lymphedema
Lymphedema is a slow onset, progressive disease characterized by an asymmetrical, inflammatory swelling, traveling distal to proximal, that can affect any body part including arms, legs, trunk, head/neck and genitals.
Lymphedema
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Lymphedema

Lymphedema is a slow onset, progressive disease characterized by an asymmetrical, inflammatory swelling, traveling distal to proximal, that can affect any body part including arms, legs, trunk, head/neck and genitals

 

A primary role of the lymphatic system is to transport proteins from the extravascular space to the heart. When the transport capacity of the lymphatic system is reduced, proteins accumulate outside the circulation (extravascular space). Accumulated proteins attract water which produces a high protein containing fluid that builds up underneath the skin (subcutaneous tissue) called lymphedema.

 

Lymphedema is a slowly progressive disorder that can lead to significant disfigurement of the extremities and other body parts. Lymphedema is generally incurable but very manageable condition that requires lifelong care and attention along with psychosocial support.

CLINICAL PRESENTATION

Stage 0:

  • Subjective complaints of affected body part feeling heavy or achy
  • No objective findings, no apparent swelling

Stage I:

  • Skin becomes more firm/fibrotic, therefore less pitting
  • Edema does not reverse to normal with elevation

Stage II:

  • Edema is observable, soft, pitting and reversible with elevation
  • No secondary skin changes are present

Stage III:

  • Gigantic, heavy limb
  • Skin becomes very firm/fibrotic and non-pitting
  • Evidence of substantial skin changes like papillomas, lobules, “peau d’ orange”)

TYPES OF LYMPHEDEMA

Primary Lymphedema:

  • Occurs when the lymphatic system does not develop properly during fetal development
  • Can be familial, genetic or hereditary

DIAGNOSIS

  • Lymphedema is primarily a clinical diagnosis made on the basis of the medical history and findings that distinguish it from other causes of chronic edema in lymphedema both feet and toes are swollen
  • A Stemmer’s sign is often used to identify lymphedema and it’s the inability to pick up or pinch a fold of skin at the base of the second toe or finger
  • When physical examination is inconclusive, other available imaging tests can help make the diagnosis (see imaging studies below)
  • Imaging Studies:

Secondary Lymphedema: occurs when there is a disruption or obstruction of the lymphatic system caused by:

  • Filariasis is a parasitic disease caused by tiny round worms which obstruct the lymphatic system (number one cause of lymphedema worldwide)
  • Surgery and/or radiation of lymph nodes due to cancer (number one cause in the United States)
  • Other: chronic venous insufficiency (CVI), deep vein thrombosis (DVT) and obesity

1.  Lymphoscintigraphy: diagnostic image of choice for lymphedema

2.  Indocyanine Green (ICG) Fluorescent Lymphography: can now be used to demonstrate superficial lymph channels and working lymphatics, in order help develop treatment options, and to confirm the effectiveness of these therapies.

3.  Duplex ultrasound to rule out a venous cause for the edema

TREATMENT

Other causes of edema that should be ruled out prior to treatment for lymphedema include chronic venous insufficiency, lipedema, cardiac, renal, hepatic, and thyroid dysfunction.

 

Pharmacologic Therapy: No drugs have been shown to be beneficial in the treatment of lymphedema. Diuretics (water pill), in particular, have not been found to be effective in removing fluid from lymphedematous quadrants and may promote the development of dehydration.

 

Complete decongestive therapy (CDT) is backed by longstanding research and experience as the primary treatment of choice for lymphedema in both children and adults. CDT involves a two-phase treatment program:

Phase 1—Reduce swelling of affected body part with daily treatments:

  • Manual lymph drainage
  • Skin care
  • Compression wrapping of limb
  • Decongestive exercises

Phase 2—Maintain decongestion with Home Maintenance Program:

  • Daily use of elastic and inelastic graduated compression garments that are properly fitted according to circumference and length to prevent lymphedema from returning
  • Choices of garments include below the knee stockings, thigh-high stockings, pantyhose, sleeves, bras, and truncal garments

SURGERY

Surgery for lymphedema has been proven largely unsuccessful and should not be considered prior to CDT. Surgical procedures are divided into two types:

  • Physiologic procedures: those performed to improve lymph node drainage such as connecting lymph system with the venous system or lymph node transplant
  • Liposuction-circumferential suction-assisted lipectomy represents a newly proposed method to reduce size of swollen limb and reduce morbidity involved in the traditional excisional techniques