ReviewLower extremity lymphedema: Update: Pathophysiology, diagnosis, and treatment guidelines
Section snippets
Etiology and pathophysiology of lower extremity lymphedema
Dermatologists frequently encounter patients with lymphedema of the lower extremities, often caused by chronic venous insufficiency and recurrent cellulitis. Although this is a relatively common problem, it has rarely been addressed in the dermatology literature. In this article, we will provide a concise review on definitions, causes, diagnosis, and treatment strategies in lymphedema.
Clinical presentation
Initially, patients with lower extremity lymphedema present with unilateral painless swelling that starts on the dorsal aspect of the foot, with eventual proximal involvement over the first year (Fig 2). The foot often has a squared-off appearance. The edema is initially a pitting edema, but over time the subcutaneous tissue becomes fibrotic, resulting in nonpitting brawny edema. The edema can then spread circumferentially if treatment is not initiated. Eventually, the involved skin becomes
Differential diagnosis
Lymphedema should be considered with any edematous extremity without pain or inflammation. Chronic venous insufficiency can be difficult to differentiate from early lymphedema because both have pitting edema, and skin changes typical of late-stage lymphedema are not yet present. Additionally, chronic venous insufficiency is often bilateral, rather than unilateral as in lymphedema. Lymphoscintigraphy may be necessary to distinguish the two, although the distinction cannot always be made since
Diagnosis
Whenever there is doubt regarding the clinical diagnosis, diagnostic confirmation can be accomplished with isotopic lymphoscintigraphy (considered the method of choice) or, if necessary, with radiocontrast lymphangiography.15 Computed tomographic (CT) scanning or magnetic resonance imaging (MRI) (MRI is superior to CT scans because it can detect water) of the lower extremity can also detect a “honeycomb” pattern of the subcutaneous tissue that is not characteristic of other types of edema.
Management
Lymphedema is associated with significant morbidity in terms of the functional, cosmetic, and emotional consequences of this chronic and potentially disabling condition. Treatment efforts are focused on minimizing the associated swelling, restoring cosmesis and functionality of the limb, and preventing potential complications associated with lymphedema (eg, cellulitis, lymphangitis). Treatments are time consuming, expensive, and involve a multidisciplinary approach among rehabilitative
Multidisciplinary treatment approach
The diagnosis of lymphedema is one with a chronic, disabling connotation. Through the joint efforts of a multidisciplinary team of lymphedema therapists, dermatologists, nurses, and occasionally vascular surgeons, a comprehensive treatment plan can be developed (see Fig 5). A description of each type of therapy should be presented to the patient with lymphedema, and a recommendation of an overall treatment plan should be discussed in detail.
There is a lack of high-quality randomized, controlled
References (34)
Managing lymphedema
Clin Dermatol
(1995)- et al.
Biology of vascular endothelial growth factors
FEBS Lett
(2006) - et al.
Obesity and the skin: skin physiology and skin manifestations of obesity
J Am Acad Dermatol
(2007) - et al.
Noninvasive evaluation of the lymphatic system with lymphoscintigraphy: a prospective, semiquantitative analysis in 386 extremities
J Vasc Surg
(1993) - et al.
Diagnostic tools for filariasis elimination programs
Trends Parasitol
(2007) - et al.
A systematic review of common conservative therapies for arm lymphedema secondary to breast cancer treatment
Ann Oncol
(2007) - et al.
Lymphedema management
Semin Radiat Oncol
(2003) American Cancer Society Lymphedema Workshop: the pathophysiology of lymphedema
Cancer
(1998)- et al.
Textbook of lymphology
(2003) - et al.
Approach to leg edema of unclear etiology
J Am Board Fam Med
(2006)
Differential diagnosis, investigation, and current treatment of lower limb lymphedema
Arch Surg
Molecular control of lymphangiogenesis
Bioessays
ABC of arterial and venous disease: swollen lower limb-2: lymphoedema
Br Med J
Stewart-Treves syndrome as a rare complication of a hereditary lymphedema
Vasa
Angiosarcoma associated with chronic lymphedema (Stewart-Treves syndrome) of the leg: MR imaging
Skeletal Radiol
The pathophysiology of lymphedema
Cancer
Radiotherapy in multilocalized lymphedema-associated angiosarcoma
Eur J Dermatol
Cited by (177)
How to Care and Minimize the Sequelae of Lower Extremity Lymphedema
2022, Seminars in Oncology NursingCitation Excerpt :It is a therapist-directed, multimodal approach, consisting of two phases.9,16 To decrease volume of the extremity, the first phase, also known as the intensive phase, incorporates exercises, a massage technique known as manual lymphatic drainage (MLD), skin care, and compression multilayer bandaging with low-stretch bandages.2,9,10,17 Duration of the first phase depends on lymphedema severity, but on average, it can continue for 45-60 minutes a day, 5 days a week, for 4-6 weeks.9,10
Lower limb lymphedema staging based on magnetic resonance lymphangiography
2022, Journal of Vascular Surgery: Venous and Lymphatic DisordersSevere lymphoedema in gynaecological cancers: Impact of pneumatic compression on quality of life
2022, Gynecologic Oncology ReportsEvaluation of Primary Lymphedema with Intranodal Lymphangiography
2024, CardioVascular and Interventional RadiologyElephantiasis mimicry in recurrent lower limb skin infections in a diabetic patient: a case report
2023, Journal of Medical Case Reports
Funding sources: None.
Conflicts of interest: None declared.