Interview
Lymphedema: It’s all about the skin
An interview with Professor Terence Ryan In discussion with Dr. Anna Towers and Anna Kennedy Introduction – Within the international lymphedema community, there are a handful of pioneers who have laid the groundwork and paved the way for the researchers and clinicians behind them. It’s important for us to acknowledge and honour their tremendous contributions. We had the opportunity to chat with Professor Ryan via Zoom, to learn more about his work and his thoughts about where lymphedema is heading, from a dermatologist’s point of view. Hopefully his work will inspire more dermatologists to become involved in the care of lymphedema.
Q
There are so many disciplines of doctors that are involved in lymphedema care. In your opinion, is that why lymphedema is still considered to be an orphan, with no real home in the world of medicine? Yes. Of course one of the problems is that physiologically speaking, the lymphatics haven’t been well seen. It’s amazing that you can take even the best textbooks of dermatology, with any drawing of the skin and show blood vessels, hair and everything, but they never put in lymphatics. So it’s just not seen, it is not visual to people by any system. There is still tremendous ignorance of its existence. ______________________________________________
Q
What do you see as the way out of this situation: that there’s no one discipline that takes ownership, and that’s taught properly about the lymphatic system? Our success in India (and therefore lymphedema) is going to get more and more publicity. The Bill Gates Foundation has given money to increase the distribution of lymphedema care. The World Health Organization (WHO) has now taken it on board and is really interested in our good results. There will be a paper published in the British Journal of Dermatology about our work. I hope dermatologists will realize that it is something they can deal with, and in my writings I tend to emphasize the focus on the care of the epidermis. I do think that the
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epidermis is to some extent, the conductor of not only blood supply but also lymphatic drainage. I don’t think people realize that the epidermis is the key focus of the treatment approach in India. ______________________________________________
Q
For disciplines to advance, they need to be recognized as such with specialists. Do you see lymphology itself, becoming a specialty? Well, I think lymphology already is a specialty, but it’s definitely a minor specialty, just as dermatology has also been regarded as a minor specialty. But it is getting better. No doubt lymphology will get better recognized too as people begin to understand it. There is still a great deal of ignorance that needs to be overcome. ______________________________________________
Q
One of the challenges in Canada getting physicians interested, is that there’s no pharmaceutical agent we can give that will help lymphedema. So it’s marginal in the view of physicians, as something they should become interested in. We have plastic surgeons now becoming interested in physiological procedures, and that’s beginning to increase interest, but it is a slow progression. It was shown in India that these people are disfigured. They have large limbs but
they also have odor and there is a tendency for them to be neglected by their families and community. I think the time is coming when people will realize that the herbal soaks that we are using can be available and effective worldwide. We’ve proven that they really work in the care of the skin, and it’s the care of the skin that resulted in an improvement of the lymphedema. We’re beginning to show that bandages and compression are not the most acceptable therapy. They are too difficult and too expensive in countries like India, and so we have to rely more and more on just simple soaks and care of the epidermis, plus movement. Of course, in India, we use yoga, but any form of movement of the skin is helpful. So a lot of our approach is self-treatment. The prescribe-able element by doctors in India is sometimes a little bit of anti-fungal or steroid cream for the eczema, but it’s all related to care of the epidermis. Mostly we are using medicinal herbals and we are promoting movement by yoga, which is culturally acceptable in India. And I think both are becoming more and more acceptable worldwide, perhaps even in Canada. ______________________________________________
Q
Cellulitis is the most serious consequence for patients with lymphedema. If there was one message to give patients to try to minimize that risk, what would that be? Wi n t e r 2 0 2 2 / 2 0 2 3