Lymphedema treatment

Lymphedema is a chronic disease caused by disorders of lymphatic drainage, which sometimes causes a significant reduction in quality of life. Lymphedema treatment counteracts the worsening of lymphedema and often requires patience, because it is costly and lengthy and may even be necessary for life. Lymphedema and lymphedema treatment are described below.

What is lymph?

Lymph is formed by the discharge of blood plasma from the blood capillaries into the body tissues, where it serves to transport various substances and cells. On the one hand, it transports nutrients and oxygen as well as certain defense cells, and on the other hand, waste products that accumulate in the tissue.

The lymph is returned to the bloodstream via widely branched lymphatic channels in the body, which can transport fluids in a similar way to the vascular system. Harmful substances and tumor cells are intercepted in the lymph nodes and rendered harmless. Edema is a swelling of tissue caused by fluid retention.

What is lymphedema?

In lymphedema, a congestion in the lymphatic system causes swelling of the corresponding body regions, for example, one or both legs (this can lead to lymphedema of the foot or lymphedema of the lower leg or lymphedema of the thigh) or one or both arms. Areas of the face or other parts of the body may also swell. The lymphatic congestion causes an increase in pressure in the tissue, which in the long term leads to damage to the skin.

For example, the skin can no longer perform its defense function properly. As a result, minor injuries can lead to the penetration of bacteria, which can then spread in the damaged skin. This then leads to an infection of the skin, which is accompanied by painful redness (erysipelas). Erysipelas therapy is usually carried out with antibiotics.

Causes of lymphedema:

Causes of lymphedema can be very different: So-called primary lymphedema develops as a congenital, genetic disease due to a malformation or malfunction of the lymphatic system. Primary lymphedema is often caused by mutations, which are either inherited or can also be newly formed. Primary lymphedema often begins on both sides of the toes and feet (toe lymphedema, foot lymphedema).

However, most lymphedema patients have secondary lymphedema. Secondary lymphedema develops, for example, in the context of an injury (traumatic) or in the context of internal diseases. A tumor or surgery or radiation is also a frequent trigger of secondary lymphedema. Other causes are inflammations such as erysipelas and insect bites. Weakness of the veins can also be the cause of lymphedema: In the context of chronic venous insufficiency, open legs (leg ulcers) with chronic inflammatory processes often occur if left untreated, which in turn can cause lymphedema. Ulcus cruris treatment is discussed elsewhere.

Symptoms of lymphedema:

Lymphedema begins with a doughy, painless swelling of one or both sides that initially forms a dent in the skin due to firm pressure. The leg feels heavy and may ache. In early stages, the edema regresses overnight, meaning it is gone by morning. As the disease progresses, the edema does not go away overnight and is present by morning.

Which doctor diagnoses lymphedema?

In the case of lymphedema, the general practitioner usually issues a referral for diagnosis and treatment of lymphedema to the specialist in internal medicine and angiology or straight to the lymphologist. The lymphologist is a physician who is specially trained in the diagnosis and treatment of diseases of the lymphatic system. There the lymphedema treatment is initiated.

How does the doctor diagnose lymphedema?

Lymphedema should be diagnosed as soon as possible so that lymphedema treatment can begin as soon as possible. The diagnosis of lymphedema is made clinically. Additional examinations are usually only necessary in unclear cases or in preparation for surgery. In primary lymphedema, swelling of the feet is found on one or both sides. The edema is initially found only on the backs of the toes, later on the forefoot. The skin folds at the base of the toes are deepened. The toes may take on a box shape. At first, the edema is soft and reversible overnight; later, as the condition progresses, it becomes coarse and progresses to the lower leg and thigh.

Due to lymphostasis, tissue changes such as fibrosis and increased local adipose tissue formation occur over time. Typical skin changes (papillomatosis, hyperkeratosis) are found in advanced stages. Often, over time, there is an extreme increase in volume of the extremity, which is not caused by the lymphedema alone, but by massive fatty tissue formation. In secondary lymphedema, there is more often thigh-emphasized swelling, and the groin as well as the hip and genital region may also be involved in the swelling.

Lymphedema stages:

Lymphedema is divided into several stages: In stage 0, the edema is not yet visible, although the removal of lymph is already disturbed. Stage 1 means that swelling is already noticed, although this recedes when the limb is elevated. The edema is soft and compressible. Stage 2 means that the swelling does not resolve with elevation of the limb alone. Stage 3 shows extensive swelling, the tissue has hardened and the skin can no longer be pressed in. There may be color changes in the skin as well as wart-like skin lesions. The skin becomes susceptible to infection.

What is the difference between lymphedema and lipedema?

Lymphedema is often confused with lipedema. In lipedema, there is a disease of the fatty tissue, which is very painful with pressure and often accompanied by bruising. In lipedema, there is often swelling of the upper and lower legs, with slender feet. In contrast, in lymphedema, there is often edema of the toes and foot. However, transitional forms to lymphedema are also seen. In unclear cases, imaging (e.g., dye tests or scintigraphy) may be used. Lipedema treatment differs from lymphedema treatment in that lymphatic drainage is often not a significant factor in lipedema.

Lymphedema treatment:

For lymphedema treatment, decongestive therapy is initiated. Lymphedema treatment includes manual lymphatic drainage by specially trained physiotherapists, during which the lymphatic channels of the body are activated so that the lymph fluid is transported towards the abdomen and chest. Lymphedema treatment by means of lymphatic drainage is performed not only on the swollen part of the body, but on all lymphatic channels of the body. Thus, when treating foot lymphedema, the leg and upper body are also treated. The lymphedema treatment is therefore to be understood as a whole body treatment.

In addition, lymphedema treatment also includes compression therapy with compression bandages. The treatment of lymphedema in the foot or lymphedema of the legs is carried out by applying firm bandages. Swollen arms and legs are tightly wrapped with bandages for this purpose. Due to the increase in pressure, the lymph is better transported out of the extremity, which leads to relief of the skin. Open skin areas can thus heal better.

During lymphedema treatment, bandages are reapplied regularly – sometimes several times a day – until the lymphedema has subsided enough for a compression stocking to be made. If the toes or fingers are involved in the lymphedema, toe caps and gloves must also be specially made. The bandages must always be worn at first, otherwise the edema will return.

Lymphedema treatment by machine lymphatic drainage:

In addition to manual lymphatic drainage, mechanical lymphatic drainage can also be used for lymphedema treatment in severe cases: Here, with the help of cuffs that fill with air one after the other, the lymph is transported towards the abdominal and chest area. Mechanical lymphatic drainage is regularly used in our practice for lymphedema treatment. After decongestion of the extremities, we fit compression stockings, mostly in flat knitting technique, which are preferably used in lymphedema treatment.

What can you do yourself to treat lymphedema?

The patient can help with the lymphedema treatment himself: Activating exercise therapy is essential for lymphedema treatment. Regular movement and breathing exercises promote lymph flow and help to remove the edema. In lymphedema treatment, exercises should be performed 2-3 times a day. Swimming or water gymnastics are ideal, as under water there is increased pressure on the lymphatic channels, thus promoting the removal of lymph. Excess weight and a too passive lifestyle can promote the development of lymphedema. An active lifestyle is recommended for lymphedema treatment.

Medication in the treatment of lymphedema:

There is currently no causal drug therapy for lymphedema treatment. Diuretics are not recommended because they increase the protein content of the tissue and thus tend to promote the development of edema.

Surgical lymphedema treatment:

Surgical treatment of lymphedema, such as lymphovenous anastomosis or lymph node transfer, is only possible in rare exceptions. Therefore, surgery for lymphedema is usually not useful.

Skin care during lymphedema treatment:

Lymphedema treatment also includes skin care: the skin is stressed both by the increased pressure in the lymphatic gaps and by wearing a compression stocking. Lymphedema treatment with the compression stocking dries out the skin and makes it susceptible to minor injuries, which increases the risk that bacteria can penetrate the skin. Due to lymphedema, the skin’s defense function is disturbed and infections (erysipelas) occur more frequently, which then often require antibiotic treatment. Skin care helps the skin to recover from compression therapy and protects against infections. Small wounds should be treated immediately with disinfectant spray. Moisturizing creams and lotions keep the skin supple.

Conclusion:

Lymphedema is a chronic, often progressive disease that should be addressed as soon as possible with effective therapy. Diagnosis and treatment of lymphedema can be performed professionally in our practice. The main pillar of lymphedema treatment is compression therapy with compression stockings. Another pillar of lymphedema treatment is manual and device lymphatic drainage as well as an active lifestyle.

Lymphedema treatment is a health insurance benefit and the costs are covered by the health insurance. However, compression stockings are prescribed for the treatment of lymphedema of the foot or lymphedema of the leg, as well as lymphedema of the arm, for which the patient must pay a smaller portion of the costs (statutory co-payment of 10%). As a rule, health insurance companies reimburse two supplies per year.