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72 Lymphoedema and ChroniC SweLLing
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TABLE 2.16 Treatment forred legs.
Initiate skin care (wash daily with a soap substitute, dry thoroughly,
moisturise with a bland emollient)
Topical steroids
Encourage exercise, e.g. chair based
Consider undersock, e.g. DermaSilk, Skinnies
Compression– class 1 British standard compression hosiery can be applied
without completing an ankle brachial pressure index (ABPI) excluding
those with risk factors for arterial disease and any red ags (neuropathy,
swelling and misshapen legs)
If there is signicant oedema or redness or the patient does not respond to
class 1 British standard compression hosiery, assess vascular status using
Doppler or employ the guidelines in the British Lymphology Society
Position Document: Assessing Vascular Status in the Presence of Chronic
Oedema and proceed to stronger compression as indicated (this may be
in the form of inelastic compression bandaging, compression
hosiery or wraps)
If there is failure to improve or respond or diagnostic uncertainty:
If there is suspected peripheral arterial disease, symptomatic varicose
veins or non-
If there are concerns about skin malignancy or other skin conditions,
consider referral to dermatology
Source: Adapted from Elwell (2020).
healing leg ulcer, refer to vascular services
factors, simple class 1 British standard compression can be considered. If the swelling is more advanced, a full holistic assessment
including a vascular assessment is required to ensure that the optimal dose of compression can be applied at the correct dose and correct rmness within RAL standard garment grades. In cases where
the redness and congestion are persistent, this will indicate that the
therapeutic dose of compression is not sucient.
Topical Steroids
In the presence of concurrent varicose eczema, topical steroid use
can be key to addressing the underlying inammation alongside
compression. The general principle is to use an ointment- based steroid at 0.1% potency, usually for one to two weeks with the emollient
daily at garment changes. This should be followed by a step- down
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approach to alternate days, then biweekly before stopping altogether.
It is not advisable to stop treatment immediately as varicose eczema
can reoccur. The dose applied should be dependent on severity and
presentation (Singh and Zahra2023).
Cellulitis
Cellulitis is an acute spreading inammation of the skin and subcutaneous tissues characterised by pain, warmth, swelling and erythema
(British Lymphology Society and Lymphoedema Support Network
2016) or skin tone changes and may include blistering. In more severe
cases, fever, sweats, headache and vomiting occur.
For the most part cellulitis is caused by Group A Streptococci
(Mortimer2000; Cox2009). However, microbiologists consider Staph-
ylococcus aureus to be the cause in some patients (Chira and Miller2010).
In lymphoedema, this may present dierently than classic cellulitis
and may not always be overtly symptomatic initially. Inammatory
markers (C- reactive protein [CRP], erythrocyte sedimentation rate [ESR])
may be raised. It is dicult to predict response to treatment (British
Lymphology Society and Lymphoedema Support Network2016).
If severe, cellulitis may require urgent hospital admission. Hospitalisation is necessary if there are signs of septicaemia: hypotension, tachycardia, severe pyrexia, confusion, tachypnoea or vomiting.
Other possible reasons for hospitalisation are:
Continuing or deteriorating systemic signs, with or without dete-
riorating local signs, after 48 hours of antibiotic treatment.
Unresolving or deteriorating local signs, with or without sys-
temic signs, despite trials of rst- and second- line antibiotics
(British Lymphology Society2022c).
It is often dicult to dierentiate cellulitis from other kinds of
inammation in the legs. Other causes of inammation include lipodermatosclerosis, a chronic condition characterised by subcutaneous
brosis and hardening of the skin on the lower legs (see Table2.15);
it is also known as sclerosing panniculitis and hypodermitis sclerodermaformis (Osti 2018). Cellulitis usually aects one leg only,
whereas lipodermatosclerosis generally aects both legs.
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TREATMENT
The treatment of lymphoedema has several aims:
Patient education on the condition and the rationale for treatment –
promoting self- care and independence and providing long- term
control of the oedema.
Improving the shape of the limb.
Restoring functional activity and improving quality of life.
Reducing the risk of infection and exacerbation.
Reducing the need for hospitalisation, e.g. by preventing celluli-
tis through prompt assessment and management (Health Service
Executive (Ireland)2019, p.16).
These aims should be applied alongside general health promotion interventions to attain the best long- term outcome for treatment
in line with supportive self- management. Promoting movement and
exercise ideally with compression is critical to ensuring venous and
lymphatic drainage (Webb et al. 2019). A focus on weight maintenance and where required weight reduction strategies is important.
The treatment of both venous disease and swelling requires education of the person with lymphoedema so that they know how to
take control of management themselves, with support from all professionals involved.
Skincare
Patients with lymphoedema require careful washing of the skin to
ensure hygiene without compromising skin integrity. Treatment
should focus on careful washing of the skin and application of emollients as well as carefulmanagement of skin folds. Emollients should
be applied after washing to maintain the protective barrier. Skincare
is equally important in achieving positive therapeutic outcomes. It is
the rst line of treatment, promoting the skin’s barriers to reduce the
risk of infection. Education of the patient is also important to ensure
that they can take immediate action when changes in the condition or
other problems arise. Changes in the skin over time due to age can
impinge on the treatment of lymphoedema. With age, skin becomes
less elastic and drier. Other problems such as malnutrition and
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chronic illnesses such as eczema aect the condition of the skin at the
onset of lymphoedema. In those who are malnourished or suering
from chronic illness, their skin may also be less elastic, dryer and fragile. In the event of a concurrent dermatological condition that may
aect skin integrity, this also needs to be treated; the risk of infection
is greater and thus the focus on protecting the skin is essential.
Skin washing and moisturising are important opportunities to
inspect the skin for signs of trauma or damage alongside monitoring
for opportunistic infections such as tinea. Education for patients and
carers is necessary to increase knowledge and self- care on how to
wash, dry and moisturise the skin to protect it from further damage.
The skin can be washed with warm, not hot, water. A non- perfumed
soap substitute is recommended to minimise the risk of triggering
skin sensitivities (Fife etal.2017). The skin can be patted dry carefully after washing, without rubbing to avoid damaging fragile skin.
Wash skin daily with mild soaps or skin cleansers that are moisturising, hypo- allergenic and have a neutral to slightly acid pH balance
(around pH 5).
Special care is needed to wash deep folds of skin on the lymphoedematous limb. It is important to ensure that the folds are cleaned of
matter that may provoke an infection. After washing, it is important
to dry in between the skin folds to ensure no moisture remains that
might cause maceration or moisture- associated skin damage (Mitchell and Hill2020). It is equally important to take care not to damage
fragile skin in the folds with undue abrasive rubbing with a towel.
The areas of focus are as follows:
Fungal infections and web- space maceration– it is essential to
ensure that skin creases are kept clean and dry (British Lymphology Society2021).
Cracks, callouses, hard skin and ssures on the feet– an appro-
priate moisturiser is essential to keep the skin in good condition
but not leave moisture that will cause further maceration or fungal infections. A risk minimisation approach is best, with emollient creams preferred to ointments (British Lymphology
Society2021).
Hyperkeratosis– an ointment is needed to soften and remove the
hyperkeratosis, along with hydrocolloid dressings and debridement (British Lymphology Society2021).
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Emollients should be applied after bathing in the direction of
hair growth to avoid folliculitis. Emollient creams are preferred for
patients wearing compression hosiery, as ointments can degrade the
stockings. It is important to leave the emollient to dry for some minutes before putting on the hosiery, as once the emollient is applied it
can be sticky and make applying hosiery more of a challenge.
Skincare is generally recommended to be administered at night
to allow for the emollient to be absorbed. However, it is important to
t in with what is suitable for the individual patient. Many people
prefer to shower in the morning or might have days in the week when
a morning shower is necessary. Whichever regimen is adopted, it
needs to be both practical and suitable for the patient’s tasks and habits of daily living, work, study and social life, as well as providing
optimal care for the lymphoedema.
Patient Education
Patients require education in order to detect early signs of lymphoedema so that they can seek health professional support and treatment
(Health Service Executive (Ireland) 2019). Education of the person
diagnosed with lymphoedema is also necessary so that they can
respond and seek help for changes in their condition, identifying early
signs of infection or cellulitis and other red ags for immediate action.
Barriers to lymphoedema patient education are found to be linked
to the ability to self- manage (Ostby etal.2018; Ridner etal.2011;
Alcorso and Sherman2016). Patient education can be separated into
lymphoedema- specic advice alongside general health promotion as
part of the assessment and follow- up programme (Table2.17).
COMPRESSION THERAPY ANDASSESSMENT
CONSIDERATIONS
The provision of therapeutic compression is essential within the
management of lymphoedema. See Chapter8 for more information
on the role and suitability of distinct types of compression therapy in
venous disease and leg ulceration.
When considering the provision of compression therapy in complex lower limb lymphoedema, specialist assistance is required and is
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TABLE 2.17
Lymphoedema- specic
patient education General health promotion
Understanding the diagnosis related
to the individual
Understanding the condition and
related management (skincare
compression, other)
Exercise and movement and the
importance of movement for the
lymphatic and venous system
Cellulitis recognition and
risk reduction
Signposting to external patient
support for further information
Lymphoedema patient education overview.
Nutritional advice
Weight management
Exercise
Footwear advice if lower limb
beyond the scope of this book. However, it is important to recognise
that short- stretch non- elastic bandages are favoured in lymphoedema
management, forming a rm encasement of the limb to compress the
lymphatics between the muscle and the bandage to reduce the backow of evacuated lymph and the production of interstitial uid. This
mechanically softens brosis and improves the eciency of muscle
and joint pumps (International Lymphoedema Framework and Canadian International Lymphoedema Framework2010, p.13).
Compression is applied with bandages, a wrap or hosiery. Bandaging is often used initially to swiftly reduce oedema volume, restore
the limb shape, soften brotic tissue,reduce skin changes and eliminate lymphorrhoea. In general, a course of intensive treatment of
two to four weeks is necessary to bring the lymphoedema under control and stabilise the condition of the limb. Once that is achieved,
hosiery is used to prevent recurrence or deterioration of the lymphoedema for a longer term. Wraps may be used in both the intensive
and maintenance stages of care. See Chapter9 on the role of at-
knit
hosiery for lymphoedema management.
If there is little improvement in the lymphoedema after four
weeks of intensive compression therapy, the patient should be reassessed (Wound Care People2019, p.23). The compression therapy
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chosen should apply the same amount of pressure in the maintenance phase as in the intensive phase. Therefore, if a wrap has been
used successfully for intensive treatment and the patient is comfortable using it, the wrap can continue to be used for maintenance
(Wound Care People2019, p.23).
It is necessary to determine whether the patient is suitable for
compression. There are many factors to consider (Table2.18). Compression is an essential part of intensive treatment, but caution is
needed in some situations, such as the presence of acute cellulitis,
TABLE 2.18 Compression assessment considerations forlymphoedema.
Factors Questions
Ability to manage
and
tolerate hosiery
Skin condition Is the skin too fragile to avoid trauma?
How committed is the patient to managing and
monitoring their condition?
Does the patient need education in compression
management? This is necessary in all assessments
Does the patient’s build, mobility or obesity make it
dicult to self- manage compression?
Does the patient have a supportive carer who can help
appropriately?
Does the patient consent to compression?
Will the bandage limit bathing?
Will the bandage prevent the patient wearing footwear
or clothing?
Is the weather too hot for the bandage to be comfortable?
Will the patient lose faith in treatment and the
therapist if the bandage or compression garment is
not right the rst time it is applied?
Will the patient’s ability to move be too restricted by
the bandage/garment?
Does the presence of varicose eczema or lymphorrhoea
require cotton liners under the bandage?
Does the severity of cellulitis in the acute phase require
a deferral of compression for a short period?
Is the pain or inammation too severe for compression?
Is the skin showing sensitivity to latex, elastane or dyes
in the compression bandage?
Does the bandage t correctly?
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TABLE2.18 (Continued)
Factors Questions
Lymphoedema
stage and severity,
shape, size and
function
of the limb
Concomitant
medical
conditions
Lower limb
arterial status
Source: Adapted from Doherty etal. (2006).
Does the patient need intensive therapy to restore limb
shape before hosiery will be suitable?
Would the distorted limb benet from custom-
knit hosiery?
at-
Will the patient’s heart failure be exacerbated by
compression? (Acute heart failure is a
contraindication)
Does neuropathy (e.g. stroke, spinal injury, spina
bida) compromise the patient’s ability to feel
pain?
Is the arterial status safe to apply compression and at
what dose?
made
pain, reduced ability to report, psychological complications, diabetes
mellitus, mild congestive heart failure, paralysis or reduced sensation. Long- term maintenance with compression garmentsis critical
and is discussed in Chapter9.
ADJUNCT TREATMENT MODALITIES
Manual Lymphatic Drainage
Manual lymphatic drainage (MLD) is a gentle massage technique
that increases the activity of normal lymphatics and bypasses ineective lymph vessels. As a result, MLD encourages the movement of
uid away from a brotic congested area of subcutaneous tissue.
MLD should always be an adjunct to compression therapy and should
only be performed by an appropriately trained specialist. Inappropriate massage of a lymphoedematous limb may damage tissues and
exacerbate oedema by increasing capillary ltration (Lymphoedema
Framework2006, p.29). More research is required to prove the benets of MLD.
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Self- Lymphatic Drainage
Self- lymphatic drainage (SLD) is a simplied version of MLD that is
used by a patient for self- treatment and/or by their carer. The British
Lymphology Society (2022a) encourages the use of SLD to maintain
the benets of MLD and encourage the continued ow of uid
through lymphatic pathways that the MLD therapist has identied as
most benecial. The benets of SLD are unproven (Doherty and Williams 2004; Lymphoedema Framework 2006) and studies report
poorer outcomes from SLD than from MLD. However, the British
Lymphology Society (2022a) recommends SLD for patients in the
absence of any other options to oer some relief of the psychological
and physical symptoms of lymphoedema.
Contraindications to MLD and SLD include acute cellulitis,
infection or erysipelas, acute or suspected (untreated) DVT and pulmonary embolism, and unstable hypertension (British Lymphology
Society2022a). The patient and/or carer must be instructed in SLD
technique by an appropriately trained specialist (Table2.19).
Other Treatment Modalities
Kinesio Tape
Kinesio taping is used to increase lymph ow, helping to stimulate
the drainage of lymph away from the aected area. It can be used
during the intensive or maintenance phases of care. It has been
TABLE 2.19
Motivated patient/carer
Patient/carer suciently dextrous to perform SLD
Time allocated for initial teaching
Teaching is progressive and enables the patient or carer to become skilled
Written instruction is given and technique is observed
Competence in the procedure and the patient’s ability to cope with
treatment are checked regularly
Patient advised on concerns and when not to administer simple
lymphatic drainage
Source:Adapted from Lymphoedema Framework, 2006: 31.
Requirements forself- lymphatic drainage (SLD).
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found to relieve tissue uid congestion, thus improving blood and
lymph circulation as well as subcutaneous lymphatic drainage. It is
similar to lymphatic drainage but allows patients to receive therapeutic benets 24 hours a day (Malicka etal.2014). It may be contraindicated in palliative care patients if the skin is very fragile
(International Lymphoedema Framework and Canadian Lymphoedema Framework2010, p.16).
Kinesio taping is a useful and safe option for early management
of upper extremity lymphoedema in women following breast cancer
treatment (Malicka etal.2014, Pajero Otero etal.2019).
Intermittent Pneumatic Compression
Intermittent pneumatic compression (IPC) is used widely. Aside
from use in lymphoedema, it is used to prevent deep venous thrombosis in hospitalised patients and can be used in intensive, maintenance or palliative care. An inatable plastic garment is wrapped
around the limb and inated with air from an electrical pump.
Cycles of ination and deation for periods of 30 minutes to 2 hours
give the limb a peristaltic massaging eect (Lymphoedema Framework2006, p.31; Zaleska etal.2014). It is believed that IPC reduces
oedema by decreasing capillary ltration, and therefore lymph formation, rather than by accelerating lymph return (Lymphoedema
Framework2006, p.31). IPC may have benets in addition to the
reduction of oedema, including improved venous haemodynamics,
reduced production of inammatory mediators, improved microcirculation, improved arterial ow to the limb and improved wound
healing (Dunn etal.2022).
There are several contraindications that must be considered
before application (Table2.20) and IPC should only be performed
by practitioners with appropriate specialist training (Lymphoedema Framework2006, p.31). IPC also may be useful in patients
who are not gaining benet from compression therapy (Young
etal.2021, p.3).
Laser Therapy
Low-
level laser therapy may be particularly helpful in lymphoedema
of the upper limb, to reduce limb volume and tissue brosis (Baxter
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