LYMPHOEDEMA:
what it is and what to do.
Let's find out together about it, its distinctive signs and the main treatment options, from complex decongestive therapy to the use of flat-knit compression stockings.
What is lymphoedema?
Lymphoedema is a chronic condition where lymph accumulates abnormally in the tissues, resulting in a persistent swelling, primarily in the limbs. It is caused by a malfunction of the lymphatic system, which impairs the drainage of interstitial liquids, leading to an increase in volume of the affected area, associated with skin hardening and, in some cases, pain or reduced mobility.
The lymphatic system, in fact, is responsible for three main functions in our organism:
- Drainage of interstitial fluids: the network of vessels that form this system collects lymph, a tissue-waste fluid containing white blood cells, and carries it to lymph nodes to eliminate toxins, metabolic waste and excess fluids, maintaining hydric balance and preventing stagnation and oedemas.
- Transfer of fats and nutrients: it absorbs lipids and fat-soluble vitamins from the small intestine and transports them into bloodstream.
- Immunologic response: lymph nodes filter lymph, trapping pathogens and activating immune defences via lymphocytes.
Under normal conditions, lymph flows through the lymphatic vessels thanks to muscle contraction and one-way valves, to ensure a steady balance between the lymphatic and the circulatory system.
Main causes and risk factors
There are two main typologies of lymphoedema. Primary lymphoedema is a congenital or hereditary condition caused by malformations of the lymphatic system. Depending on the stage of life in which it may manifest itself, we make a distinction among congenital lymphoedema (present at birth), early lymphoedema (arising during childhood or adolescence) and late lymphoedema (appearing after the age of 35 without a clear cause). Secondary lymphoedema, on the other hand, is caused by damages or obstructions of the lymphatic system as a result of surgery, radiotherapy, traumas, infections, and chronic diseases, such as venous insufficiency, which may impair lymphatic drainage.
There are also some factors that may increase the likelihood of developing a lymphoedema , such as surgery with removal of lymph nodes, oncological therapies (radiotherapy, chemotherapy), chronic infections of the skin or subcutaneous tissue, repeated traumas, or medical conditions that impair lymphatic circulation.
Lymphoedema is a progressive condition, but early diagnosis and appropriate treatments can limit its effects and improve the patient's quality of life.
Stages, symptoms, and signs
According to the classification of the International Society of Lymphology (ISL), there are four stages:
- Stage 0 (subclinical lymphoedema)
- The lymphatic system is damaged, but there are no obvious signs of swelling or changes of the skin tissue yet.
Feeling of heaviness or tension in the limb may occur.
- Stage 1 (early lymphoedema)
- The oedema is visible but tends to disappear spontaneously with rest and elevation of limbs. The skin is still soft and pressure with a finger leaves a temporary dimple (Fovea Sign). Lymphatic fluid accumulates, but no permanent tissue changes are observed.
- Stage 2 (mild lymphoedema)
- The volume of oedema increases; it gets permanent and does not disappear with rest. The skin changes its consistency, becoming thicker and harder due to tissue fibrosis. The Fovea Sign may be less visible or absent.
- Stage 3 (severe lymphoedema)
The limb is significantly enlarged and misshapen, even to elephantiasis. The skin changes; it is thickened, with skin alterations and folds. Skin ulcers and recurrent infections are possible. The mobility of the limb may be impaired.
Symptoms may vary depending on the stage, but the most common are:
- Progressive swelling usually of a limb, but may also affect the torso or other areas
- Feeling of heaviness or tension in the affected area
- Alterations of the skin, which may become harder, drier or less elastic
- Pain or discomfort, especially in advanced stages
- Reduced mobility of the affected limb
- Discontinuous swelling sensation, especially at the end of the day
- Difficulty in putting on rings, shoes, or clothes in the affected area
- Fovea Sign,the pressure with a finger leaves a temporary mark on the skin
- Increased sensitivity or stiffness of the limb compared to the opposite side
- Alterations of the skin, which may appear shinier or more stretched.
Diagnosis
An early diagnosis of lymphoedema is crucial to prevent complications and start an appropriate treatment in a timely manner. The diagnostic process is based on a thorough clinical evaluation supported, if necessary, by instrument tests to confirm the diagnosis and determine the extent of lymphatic damage.
The first diagnostic phase is anamnesis and physical examination, during which the doctor gathers information on the patient's medical history (family history, surgeries, traumas, infections) and analyses the reported symptoms. Inspection and palpation of the affected area further allow for the detection of characteristic symptoms of lymphoedema, including the possible presence of hardened skin, the Fovea Sign (persistence of the imprint after skin pressure) and differences in circumference between limbs.
If the clinical assessment is not conclusive or a more in-depth analysis is required, instrumental investigations are performed, including:
- Lymphoscintigraphy, a reference exam for the study of lymphatic flow, useful for identifying any obstructions or alterations in the lymphatic circulation.
- Tissue ultrasound scan, used to exclude other possible causes of oedema, such as venous insufficiency or lipoedema.
- MRI or CT scans, used in the most difficult cases to obtain a detailed view of the lymphatic structure and surrounding tissues.
- Bio-electrical impedance analysis (BIA), body composition analysis to assess fluid distribution and the degree of water retention.
Thanks to an accurate and timely diagnosis, early intervention is possible, thus improving the management of the disease and the patient's quality of life.
Treatment
There is no conclusive therapy for lymphoedema, but its treatment aims to reduce swelling, improve the function of the affected limb and prevent complications.
Currently, the most effective treatment is Complex Decongestive Therapy (CDT), a multimodal approach that combines several techniques to reduce oedema and maintain results over time.
CDT consists of two main phases: the intensive phase called decongestive, where the volume of oedema is reduced through daily treatments, and the maintenance phase, in which achieved results are stabilised to prevent a progression of the pathology. This latter phase is crucial and should be pursued consistently throughout life due to the chronic nature of lymphoedema.
During the decongestive phase, the treatment is based on two essential elements: Manual Lymphatic Drainage (MLD) and compression by compression bandaging.
MLD is a specific massage technique that stimulates the lymphatic system, facilitating the reabsorption of lymph into lymphatic vessels and its outflow towards uncompromised lymph node positions, thus helping to reduce swelling and improve patient comfort.
After drainage, a compression dressing with short-stretch bandages is applied, which is indispensable for preserving achieved benefits and promoting fluid reabsorption. This type of bandage exerts targeted pressure, supporting lymphatic return and limiting fluid stagnation. In the intensive phase of treatment, bandages must be kept in place 24 hours a day to ensure maximum therapeutic effectiveness.
During the maintenance phase, compression bandaging is replaced by daily wearing of flat-knit graduated compression stockings, designed to ensure the effective containment of oedema, and stabilise limb volume. Flat-knit stockings are characterised by their rigid and less elastic structure compared to circular-knit stockings; they allow to exert a constant and uniform therapeutic pressure to counteract the accumulation of fluids. Model and compression class should always be determined by a specialist, depending on the stage of the pathology. Thanks to their high degree of resistance and capacity to maintain therapeutic pressure over time, they are an indispensable solution for a long-term control of the pathology.
A timely management of lymphedema is essential to reduce the risk of exacerbations. Consulting a specialised physician allows you to get an accurate diagnosis and define a customised treatment plan aimed at controlling the oedema and preventing complications
Daily life and prevention
- Physical activity and movement
Regular exercise helps stimulate lymphatic drainage and maintain mobility. Low-impact activities such as walking, gentle exercise, and swimming are recommended. It is important to avoid high-impact exercises or excessive strain.
Skin care and hygiene
The skin of people with lymphedema is more fragile and prone to infections, such as erysipelas. It is essential to adopt a correct hygiene and protection routine. Always keep your skin hydrated, avoid traumas, insect bites and wounds, which could represent a gateway for infections.
Patient education and lifestyle
To keep lymphedema under control it is essential to adopt correct daily habits. Avoid situations of excessive heat (e.g. saunas, hot baths, prolonged exposure to the sun), which can increase swelling; wear comfortable clothing and shoes, avoiding tight clothing that hinders circulation; maintain a healthy body weight, since overweight can aggravate lymphedema; put your limbs in elevated position regularly to facilitate lymphatic drainage.
Following these guidelines will help you manage lymphedema effectively, thus improving your overall well-being.
Also, have regular check-ups with your doctor.
Psychological support
Face lymphedema can be emotionally challenging. Psychological support can help you manage stress, improving your well-being and ability to live with this condition. Lymphedema has a significant emotional and social impact. People living with it can feel frustrated or isolated because of physical changes. Psychological support, along with support networks such as patient groups or associations, can offer practical and emotional help to deal with the daily challenges of lymphedema. impatto emotivo e sociale significativo. Le persone che convivono con esso possono sentirsi frustrate o isolate a causa dei cambiamenti fisici. Il supporto psicologico, insieme alle reti di supporto come associazioni o gruppi di pazienti, può offrire aiuto pratico ed emotivo per affrontare le sfide quotidiane del linfedema.
Conclusion
Seeking medical attention as soon as you suspect the first signs of lymphedema is essential for its effective management.