Masterclass GUIDES Introduction Lower extremity lymphedema is an under recognized and under managed clinical condition. Too often unrecognized, the correct diagnosis of lymphedema is essential for appropriate clinical management.1,2 Often undermanaged, or potentially mismanaged through the liberal use of diuretics, the result can lead to secondary unintended consequences and result in progressive adipose deposition, tissue fibrosis, increasing limb volume, heaviness, functional difficulties,increased susceptibility to recurrent episodes of cellulitis, and overall higher healthcare utilization.
Lymphedema in Clinical Practice
Keywords ■ Lymphedema ■ Chronic edema ■ Phlebolymphedema
Table 1: Medications commonly associated with edema. Class
Specific medications
Antidepressants
Monoamine oxidase inhibitors, trazodone
Antihypertensives
Beta-adrenergic blockers, calcium channel blockers, clonidine (Catapres), hydralazine, methyldopa, minoxidil
Antivirals
Acyclovir (Zovirax)
Chemotherapeutics
Cyclophosphamide, cyclosporine (Sandimmune), cytosine arabinoside, mithramycin
Cytokines
Granulocyte colony-stimulating factor, granulocyte-macrophase colony-stimulating factor, interferon alfa, interleukin-2, interleukin-4
Hormones
Androgen, corticosteroids, estrogen, progesterone, testosterone
Nonsteroidal anti-inflammatory drugs
Celecoxib (Celebrex), ibuprofen
This Masterclass Guide provides an overview of this condition in clinical practice.
What is Lymphedema? Assessment of Lymphedema
■ Lymphedema is the result of a loss of the finely tuned balance of
microvascular tissue fluid production and recovery through the lymphatic vasculature, chronic inflammation, and loss of integrity of the lymphatic endothelial cell GCX 3-7
■ Primary lymphedema is due to a genetic mutation resulting in abnormal
lymphatic vascular development causing either a structural or functional abnormality that impairs proper drainage of lymphatic fluid, and is further categorized as congenital (identification based upon abnormalities identified shortly after birth), praecox (abnormalities identified most often during teenage years or early adulthood), or tarda (typically occurring after age 35) 3
■ Due to the challenges associated with accurately diagnosing lymphedema,
clinicians should carefully consider the differential diagnosis. Patients can be broadly segregated by those with unilateral asymmetric or bilateral leg edema, and by acuity of onset
■ Chronic venous insufficiency ■ Lymphedema ■ Glycocalyx
What Are the Stages of Lymphedema? Stage 0
■ Latent or subclinical; no evidence of swelling; subjective symptoms Stage I
Acute onset unilateral leg edema
■ Consider DVT and evaluate using duplex ultrasonography. If DVT has been excluded, patients should be evaluated for musculoskeletal injury or cellulitis, which should be evident based on history and physical exam findings
Bilateral leg edema
■ The differential diagnosis includes medication-induced edema, acute heart failure, end-stage renal disease, and bilateral DVT. Common medicationinduced edema is often forgotten within the differential, yet is well described in the literature. Clinicians should closely examine medication lists as a significant proportion of patients now take antihypertensive medications commonly associated with edema (Table 1) 8
■ Early accumulation of fluid; usually pitting; subsides with elevation Stage II
■ Swelling rarely reduced with elevation; pitting still present in early stage II, whereas pitting is absent in later stages as fibrosis and fat deposition begin
Stage III
■ Lymphostatic elephantiasis; non pitting with trophic skin changes, further deposition of fat and fibrosis, and warty overgrowths 9
Figure 1: Lymphosomes of the body.30
Unilateral leg edema
Temporal Submental Subclavicular
■ The differential diagnosis includes chronic venous insufficiency, chronic
lymphedema, Baker’s cyst, May-Thurner syndrome, pelvic tumor, complex regional pain syndrome, syndromic limb hypertrophy (Klippel-Trenaunay syndrome and Proteus syndrome), and poor calf contractility (radiculopathy, stroke). Duplex ultrasonography can be helpful to identify chronic venous insufficiency and Baker’s cyst
Lateral axillary
Occipital Subscapular Pectoral
Superior inguinal Superior inguinal Inferior inguinal Popliteal
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Wound Masterclass - Vol 2 - March 2023
© Copyright. Wound Masterclass. 2023 Image available from Suami, H., & Scaglioni, M. F. (2018). Anatomy of the Lymphatic System and the Lymphosome Concept with Reference to Lymphedema. Seminars in plastic surgery, 32(1), 5–11.