The importance of early diagnosis of Lymphoedema for medical practitioners

 

The Australasian Lymphology Association (ALA), the peak professional organisation promoting best practice in lymphoedema management, research and education, is committed to promoting the development of lymphology in Australasia to those at risk of developing the disorder and to those able to diagnose lymphoedema – medical practitioners.

With early intervention being the primary means of limiting the impact lymphoedema has on patients, a key aim of the month-long awareness campaign is to inform medical practitioners and those in the high risk groups of the early signs and symptoms to limit the progression of the disorder.

Lymphoedema is a chronic accumulation of protein rich fluid in any part of the body (limbs, trunk, breast, genitalia and head/neck). It is due to an imbalance between interstitial fluid production and transport of lymph fluids - A life threatening illness is replaced with a life-long distressing and debilitating condition.

 

Causes of Lymphoedema

Any major damage to the lymphatic system causes a life-long risk of lymphoedema.

  • Primary – due to a congenital malformation of the lymphatics

  • Secondary – due to damage to lymph nodes (surgery/radiation), infection or trauma

  • Mixed lymphoedema – combined with venous disease, immobility or lipoedema (abnormal deposition of fat tissue)

 

Patients most at risk of developing secondary Lymphoedema include:

  • Any patient who has been treated for cancer where the lymph nodes have been removed or damaged during surgery and/or radiation

  • Cancer patients who have been identified as being most at risk include those treated for breast, melanoma, gynecological and prostate cancer.

 

Key risk factors

The stage, location and severity of lymphoedema, together with the individual circumstances of the patient, play a vital role in managing the condition. Key risk factors include:

  • the extent of surgery, lymph node dissection and radiation treatment

  • wounds, trauma, infection (cellulitis & fungal infections)

  • increased body mass index (BMI) and immobility.

 

Early signs and symptoms

Many conditions may cause similar symptoms however, if early warning signs are experienced, other possible causes of the swelling should be excluded.

Early warning signs of lymphoedema can be intermittent and may include:

  • transient swelling of a limb or other region of the body after surgery, even if intermittent

  • infection (due to lymph stasis) is often the first sign of a problem

  • feelings of aching, heaviness, stiffness in the affected body part

  • limitation of movement

  • tightness or temperature changes to areas of the body clothing, jewellery or shoes may feel tighter

  • swelling may be aggravated by heat, overuse, sustained positions and prolonged inactivity and more obvious at the end of the day

  • permanent swelling of more than 3 months (pitting in early stages)

  • usually asymmetrical, especially when affecting the upper limb

  • Stemmer’s sign positive (unable to pinch the skin at the base of the second toe).

 

Diagnosis

  • Clinical diagnosis. Need to exclude recurrence of malignancy, DVT, venous insufficiency, heart/renal/hepatic failure and myxoedema

 

Referral to accredited Lymphoedema Practitioner

Lymphoedema is a chronic condition that qualifies the patient for a Chronic Disease Management Plan
If diagnosis of lymphoedema is confirmed, referral to an ALA Accredited Practitioner is recommended and can be found in your region through the National Lymphoedema Practitioners Register (NLPR) - Find a practitioner

 

Lymphoedema management

Complex Lymphoedema Therapy (CLT) or Complex Decongestive Therapy (CDT) is the treatment of choice in Australia consisting of:

  • Skin care

  • Exercise

  • Manual Lymphatic Drainage

  • Compression Therapy

NOTE: Information on lymphoedema management is available here.

 

Cellulitis in patients with Lymphoedema

  • Pathogen is usually Strep. pyogenes - Phenoxymethylpenicillin 500mg q6h for minimum of 14 days

  • Evidence of Staph. Aureus (folliculitis, pus or dermatitis) - Flucloxacillin 500mg PO q6h

  • Cephalexin 500mg q6h for penicillin hypersenstivity, or Clindamycin 450mg q8h for penicillin allergy

  • May need antibiotics for up to 1-2 months for complete resolution

  • Antibiotic prophylaxis if 2 or more episodes of cellulitis in 12 months

Please see Managing Cellulitis Consensus Guideline for further details.