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62 Lymphoedema and ChroniC SweLLing
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The Stemmer Sign
A positive Stemmer sign (swelling, inammation and adipose deposition thickening the skin, making it more dicult to lift and pinch
the skin on the dorsum of the hand or foot; Figure2.3) makes lymphoedema likely, although a negative sign does not rule out earlystage lymphoedema (Greene and Goss2018, p.14).
The Stemmer sign is used as part of a physical examination to
support the diagnosis of established lymphoedema. If the examiner
cannot pinch the skin of the dorsum of the foot or hand, then this
positive nding is associated with lymphoedema. Checking for a positive or negative sign as part of the physical examination allows the
clinician to correlate what is presented and seen and felt alongside
taking the patient’s history of the onset. It is a simple check to identify that the swelling is rm and established.
FIGURE 2.3 Stemmer sign.
Source: Reproduced by permission from Kamijo etal.2021.
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TABLE 2.10
Examination of
tissues and skin Signs of lymphoedema
Texture Tissue is soft and pitting
Skin changes Skin folds, from creases in the skin predominantly
Temperature Whether the limb is warmer or cooler than normal
Sensation Consider lack of sensation or reduced sensation
Colour Darkened skin tone or staining located to one area or
Physical examination ofthe skin andtissues.
Feels less elastic and rm
Changes in consistency of the tissue or compare to a
unilateral limb for comparison
Thickened coarse skin with positive Stemmer sign
noted in the toes and around or above the
ankle area
Hyperkeratosis, thickening of the outer layer of the
skin, which contains a tough, protective protein
called keratin
Lymphangiectasia, a pathological dilation of
lymph vessels
Papillomatosis, characterised by the appearance of
numerous papules
Peau d’orange (French for ‘orange peel skin’ or, more
literally, ‘skin of an orange’), describing hair follicles
getting buried in the oedema resembling
orange peel
bilateral can be venous congestion and will vary
dependent on skin tone
The physical examination of the texture of the skin and subcutane-
ous tissues should note skin changes within the assessment (Table2.10).
Simple Steps inPhysical Examination
Look– for asymmetries, skin conditions, congestion. Pay particu-
lar attention to skin changes (peau d’orange, papilloma, brosis).
Touch and feel– palpation, pitting, check Stemmer sign, rmness.
Ask questions – subjective assessment can provide essential
information to form the diagnosis and future treatment plan.
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TABLE 2.11
Stage 0 Clinically normal limb with abnormal lymphatic transport
Stage 1 Early oedema responsive to limb elevation
Stage 2 Firmer tissue with fewer signs of pitting oedema
Stage 3 Fibroadipose deposition and skin changes
Source: Adapted from International Society of Lymphology (2013) and Greene and
Goss (2018), p.12.
Stages oflymphoedema.
that is apparent only with lymphoscintigraphy
unresponsive to elevation
Step4: Staging andSeverity
The pathophysiology and staging of lymphoedema are the same
whether the problem is primary or secondary (Greene and Goss2018,
p.12) (Table2.11).
In the initial stages of swelling, mild or uctuating pitting oedema
may be noted. Pitting oedema occurs when excess uid in the body causes
swelling that indents when pressure is applied, for example with a nger
pressing down, or marks that can be noted as indents from socks. This
early swelling usually resolves with elevation. As symptoms progress from
Stage 1 to Stage 2, the subsidence of swelling of the aected limb becomes
more and more resistant to elevation or overnight rest. This indicates that
the lymphatic system is increasingly unable to maintain uid balance by
collecting and transporting uid from the interstitial spaces to the circulation and has become congested (British Lymphology Society 2020). If
symptoms progress further or are left untreated, unevenly distributed
brosis and adipose tissue replace the interstitial uid. Pitting oedema
then becomes dicult or impossible to treat and, as a result, subcutaneous
tissues become thickened and rm, with the development of deep folds
and the emergence of skin changes (British Lymphology Society2020).
According to the International Society of Lymphology (2013),
the severity of oedema is classied as:
Mild (<20% increase in limb volume)
Moderate (20–40%)
Severe (>40%)
Step5: Measurements
Limb volume measurement is a method of measuring that provides a
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swelling; it can be conducted with a tape measure, perometer or
water displacement. For the most part and within community settings, limb volume measurement may not be attainable, thus simple
measurements at key circumference points are recommended. It is
noted that tape measures can beunreliable for accurate monitoring
(particularly in children) because of the diculty of measuring the
same position over time and holding the tape with the same tightness
(Houwen etal.2022; Greene and Goss2018, p.12).
Step6: Psychosocial Impact
The assessment must consider the negative psychosocial impact on
those aected. People with lymphoedema have statistically signicantly poorer social well- being, including self- perceptions of body
image and appearance, and diminished sexual and social functioning.
They may experience negative self- identity, emotional disturbance and
psychological distress, and may feel socially isolated or marginalised, as
if they are a nancial burden and unsupported at work (Fu etal.2013)
(Table2.12). Key factors that impair the quality of life in people with
lymphoedema include the frequency of acute inammatory episodes,
the presence of pain, skin quality and reduced limb mobility, alongside
nancial concerns (Bowman etal.2020; Morgan etal.2005).
TABLE 2.12
Impact Contributing factors
Body image disturbance Feeling that aected limbs are ugly,
Grief Loss of the person’s preFrustration, anxiety Lack of nancial support
Fear Afraid that lymphoedema will get worse
Guilt Feeling that the person did something
Sadness Having to wear unfashionable or unsexy clothes
Depression Need for daily management of symptoms
Source: Adapted from Fu etal. (2013).
Psychosocial impacts oflymphoedema.
unattractive, disgusting
lymphoedema being
Burden of daily lymphoedema management
Lack of importance accorded to lymphoedema
by health services
themselves to cause the lymphoedema
to t the swollen limb
Impairment of physical function
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People with lymphoedema therefore require health professionals
to initiate a conversation to identify how the disease is aecting them
psychosocially, and to discuss ways to manage the impact, setting
realistic expectations for what can be done and the kind of support
that might be available. The quality- of- life measure for limb lymphoedema (LYMQOL) (Keeley et al. 2010) is a practical tool for
assessing the impact of symptoms on the patient, to help inform clinical decisions and to measure the results of progress in treatment.
MANAGEMENT CHALLENGES
Eective and appropriate management of lymphoedema requires a
system- wide approach to minimise variations in outcomes and quality
of care and to reduce costs. Untreated and poorly managed lymphoedema not only severely impairs patients’ quality of life and increases
their long- term health risks; it also has a high cost for health services
and in some cases can triple the cost of treatment (Healthy London
Partnership2020). Late diagnosis can be reective of inecient systems and processes, which in turn can result in a convoluted patient
journey leading to a negative impact from social and economic perspectives. Sub- therapeutic management for leaking legs alongside unnecessary recurrent cellulitis infections should be challenged and considered
as patient harm (Atkin etal.2021). Providing sub- therapeutic management, largely related to the sub- optimal dosage of compression, is not
an ecient method for optimising nursing time (Table2.13).
Good management includes accurate and timely diagnosis. Early
recognition and prompt and eective treatment enable symptoms
to be controlled and prevent escalation (Health Service Executive
(Ireland)2019, p.33). Monitoring for signs of lymphoedema is particularly important in patients with cancer, vascular conditions or
current wounds, those who use a wheelchair and the elderly (Health
Service Executive (Ireland)2019, p.33).
Delayed or absent diagnosis can lead to inappropriate treatment,
late referral to appropriate health services, the development of complications and co- morbidities, and exacerbations of the impact on the
person’s quality of life. It may also cause additional physical symptoms such as diculty in moving the aected area, general discomfort
and heaviness from unmanaged swelling, recurrent skin infections
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TABLE 2.13 How can thecomplexities beaddressed fora better system–
what can Ido asa clinician?
Risks to patient
and system
Sub- therapeutic
management of
‘leaking legs’
Recurrent
cellulitis
Convoluted
patient journey
Negative social
and economic
impact
Risk reduction focus Considerations and
interdependencies
Prompt assessment and
therapeutic management
to reduce the risk of
avoidable harm
and infection
Recognition of cellulitis as
an early warning sign
that swelling is evident
Prompt assessment and
advice on skincare and
optimising oedema
management to reduce
the potential recurrence
of cellulitis and sepsis
risk and reduce harmreducing risk factors
through self-
Ensuring eective
therapeutic compression
garments to reduce
recurrent infections
Ensuring a smooth pathway
that reects earlier
recognition,
identication,
intervention and
management across
the pathway
Identifying where there is a
multifactorial
biopsychosocial negative
impact on patients and
the wider healthcare
system and workforce
management
Lack of therapeutic
management could
be considered an
avoidable harm
Provision of patient
education to optimise
self- management
Raising public
awareness of lower
limb conditions so
patients recognise
when to seek help.
Improve healthcare
professionals’
knowledge and skills
in recognition and
signposting to
appropriate services.
Local pathways that are
collaborative and
seamless across
primary care,
community,
specialist and
acute services
Reviewing local
systems to identify
gaps in provision and
the negative impact
on the population
and workforce
(Continued)
68 Lymphoedema and ChroniC SweLLing
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TABLE2.13 (Continued)
Optimising
systems,
processes
and resources
Identifying system pathways
to ensure longsupport is available for
patients to enable
long self-
lifemanagement, e.g. hosiery,
reassessment and review
if changes in condition
Identifying pathways to
support selfe.g. access to therapeutic
compression garments in
a timely manner, and
patient- initiated
follow-
term
management,
up
and a change in the texture of the skin. Watery lymphorrhoea (lymph
uid) leaking from the skin and unmanaged swelling can cause a
breach of skin integrity and increase the risk of infection. These complications can lead to patients experiencing psychosocial problems
such as forced absence from work, isolation, absence from social
activities, anxiety and depression, increasing the need for health service intervention and demand on NHS resources and economic costs.
Multidisciplinary
collaboration ensures
improvements are
made where harm is
occurring.
Consideration for data
collection, e.g. audits
to identify areas of
good practice
or concerns
Leadership to inuence
and shape future
systems to address
health inequalities
and continuous
improvement
LYMPHOVENOUS DISEASE
It is important to be alert for a number of changes in the appearance
of the skin, veins and underlying tissue that indicate the presence
oflymphovenous disease, a progression of lymphoedema with venous
involvement. The presence of DVT and red legs indicates unmanaged
or poorly managed lymphovenous disease. The most common presentation of DVT in patients with advanced cancer is asymmetrical
bilateral leg oedema, but it is not limited to this group; DVT is a risk
factor for those with venous disease. Progression of venous disease
makes the patient’s condition and treatment more complex. It is
therefore important to understand the factors involved and the role of
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cellulitis, lymphorrhoea, inamed or red legs and DVT so that they
can be recognised, diagnosed and managed appropriately.
Cellulitis is frequently misdiagnosed (Patel etal.2019). The signs
of cellulitis are similar to those of inamed or red legs and congestion
(see later Table2.15). However, vigilance for cellulitis is important, as
it will also complicate and exacerbate lymphoedema and make treatment more dicult (see Chapter5 for the signs of venous disease).
Lymphorrhoea
Lymphorrhoea indicates unmanaged, uncontrolled lymphoedema,
and carries severe risks to the patient’s health and quality of life
(British Lymphology Society2023) and utilises signicant healthcare
resources. Lymphorrhoea occurs because the pressure inside the
tissues has become too great to contain the oedema. As a result, the
lymphatic uid leaks from the skin. This causes skin maceration and
increases the risk of cellulitis. The most common place for lymphorrhoea to occur is the legs, but it can aect any area of the body.
Common triggers for lymphorrhoea are:
Immobility and dependency.
Non- adherence to therapeutic management.
Health changes, such as the development of breathing dicul-
ties or cellulitis.
Low albumin protein level.
Oedema at the end of life (i.e. ‘leaky legs’).
Lack of recognition and ineective management by healthcare
practitioners.
Lymphorrhoea may also be a secondary symptom of cellulitis,
triggered by the inammatory response to cellulitis. Prompt management is essential to avoid the cascade of harms that may result from
uncontrolled ‘leaky legs’. There is a need rst to establish the underlying cause of the lymphorrhoea, to inform the optimal management
approach. Lymphorrhoea usually responds well and rapidly to an
appropriate therapeutic intervention including skin care and compression. Once controlled, the risk of cellulitis is reduced and the
patient can regain a better quality of life (Patel etal. 2019; British
Lymphology Society2023). There are signs that can increase the risk
of lymphorrhoea for the more vulnerable groups (Table2.14).
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TABLE 2.14
oflymphorrhoea.
Recent exacerbation of poor health
Recent and sudden reduction in mobility
Taut, shiny skin
Inammatory skin conditions
Previous lymphorrhoea
optimal management
SubLymph blisters on the skin
Palliative
General systemic overload
Source: Adapted from British Lymphology Society (2023).
Signs that thepatient might beat increased risk
Red or Inflamed Legs
‘Red legs’ is the predominant term used to describe congestion and
inammation in the lower legs; it is a condition commonly seen in
patients with chronic venous disease and chronic oedema, or lower limb
dermatological conditions (Elwell2020) and has been an important tool
to dierentiate between cellulitis and the inammatory processes present. An episode of acute lipodermatoschlerosis is often misdiagnosed as
cellulitis. Studies have shown that around 28–33% of patients treated for
cellulitis are misdiagnosed, which subsequently leads to avoidable and
costly hospitalisation and potentially hazardous use of intravenous antibiotics that may compound the evolution of antibiotic- resistant bacteria
(Edwards etal.2020). Legs need to be assessed with care, as conditions
related to them may have several causes that require dierent treatments. The British Lymphology Society’s Red Legs Pathway is a useful
guide to assessment and management (Elwell2020) and is a tool to differentiate between cellulitis and the inammatory causes of ‘red legs’.
It is important to note that the term ‘red legs’ is not always a useful term for darker skin tones; the expectation of redness can cause
the condition to be missed. At the time of writing there is no national
consensus on a new descriptor. It is recognized that there is a need to
establish skills in assessing signs and symptoms in people with darker
skin tones within the health care sector more broadly and lower limb
management specically (Wounds UK, 2021).
When examining the limb the aim is to recognise inammation. In
lighter skin tones the inammation can be perceived as red or a livid dark
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brown due to the higher contrast. In darker skin tones, the colour change
can be more subtle but also with a red or even purple hue or simply a
darkening of their skin tone. Thus comparison to the other limb or
another body part is critical as is asking the patient for their impression of
the skin changes. Feeling for warmth or changes in texture is important.
Red legs may present either bilaterally or unilaterally. There are
many possible dierential diagnoses for each. Bilateral redness with
wet and leaky legs indicates lymphorrhoea. If redness is unilateral,
and the patient is also unwell with fever, raised temperature, pain and
related symptoms, cellulitis should be considered. Cellulitis is rarely a
cause of problems when redness is bilateral (British Lymphology
Society and Lymphoedema Support Network 2016). For dierential
diagnosis see Table2.15. For treatment of red legs see Table2.16.
Treatment for red legs begins with daily washing with a soap
substitute in warm water, followed by careful but thorough drying of
the skin (patting dry) and the application of an emollient. A focus on
appropriate compression therapy to address the unmanaged swelling
is essential. In the event of mild swelling with no associated risk
TABLE 2.15 Dierential diagnosis ofred legs.
Bilateral red legs– in a
well patient
Lipodermatosclerosis
Varicose eczema
Gravitational dermatitis
Contact dermatitis
Fungal infection/Intertrigo in
skin folds
Drug-
induced
induced redness, e.g. sunburn
Heat-
and radiators/open res/hot
water bottles
Underlying medical condition–
consider diagnosis of heart failure
Source: Adapted from Elwell (2020).
Unilateral red legs– what
to consider
Assess deep vein thrombosis (DVT)
risk and rule out if suspected via
local policy
Consider venous
hypertension– varicosities
Acute lipodermatosclerosis
Phlebitis
Staining red ags: In unilateral leg
consider extrinsic venous
compression due to undiagnosed
tumour/recurrent disease– exclude
with appropriate pelvic
investigation/blood tests
DVT– exclude with venous duplex
and D-
dimer
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