Skin care remains a fundamental part of care for those with lymphoedema. This can either be done by the individuals themselves, or, in certain circumstances, can be therapist-led. The British Lymphology Society (BLS) have advocated the importance of good skin care as far back as 2001 (BLS, 2001). They have historically classed it as one of the ‘four cornerstones of care’. However, there remains little in the way of evidence-based advice that can promote a minimum standard of care.
The structure and functions of skin
When discussing the importance of skin care for patients with lymphoedema, it is essential to remind ourselves what the skin does and how it relates to the lymphatics. Many diagrams of the skin do not include the lymphatics; therefore, it is not always clear how one has an impact on the other, and vice-versa. Figure 1 shows how the superficial lymphatics appear in a cross-sectional diagram. The proximity and position of these in relation to the other structures offers some explanation as to why there are interactions.
The skin consists of two main layers—the epidermis and dermis (Figure 1).
The epidermis is the outer covering. It contains keratin on the surface that acts as a barrier to resist friction and prevent infection.
The dermis sits beneath the epidermis. Its main role is to support the epidermis and supply it with nutrients. The dermis contains connective tissue (collagen and elastin), blood and lymph vessels, and nerves. Hair follicles and sweat glands represent invaginations of epidermal structures into the dermis.
The subcutaneous tissues consist mainly of adipose, which is an insulating layer, and is vitally important in the conservation of body heat. It also allows the skin to move over the underlying tissues and adds to body shape.
Function of the skin
- Protection: the skin provides protection from physical damage, trauma and infection
- Immune function: the lymphatic system houses the immune system. With a healthy immune system, the skin has the potential to recognise harmful substances that may enter the body, and then activate the immune responses to eliminate them
- Inflammation and repair: the skin is frequently damaged, so its repair functions have to be good. Inflammation is one of the initial responses of the living tissue to injury (that injury may be physical, such as accidental, surgical trauma or radiation; chemical, such as acid; or necrosis from loss of blood supply)
- Sensation: the skin is the largest sensory organ. It senses danger and so, provides a protective function and also touch and pressure sensation. This function of skin is supported by its presentation on different aspects of the body (e.g., very thick on soles of the feet/palms of hands and delicate on the eyelids, scrotum and penis).
- Temperature regulation: the skin is important for controlling heat loss
- Endocrine—vitamin D production: on exposure to sunlight (especially UVB radiation), a substance found in the skin cells (7-dehydrocholesterol) is converted to cholecalciferol. This is the precursor to vitamin D.
- Psychosocial/sexual: the skin forms part of how the world sees us. Adornment of the skin is part of human behavior. It can help identify our culture, personality and age. We also express some emotions through the skin, exhibited by colour change.
Thinking about the structure and function of the skin helps healthcare professionals (HCP) understand the profound effects lymphoedema can have on skin. Of course, the impact of lymphoedema goes far beyond skin complications; for example, the impact on body image; while this is beyond the scope of this article, acknowledgment is paramount.
Current available protocols
The more recent publication of the All-Ireland Lymphoedema Guidelines offers a skin care protocol as part of the resources in the appendices of the guidelines (Health Service Executive, 2022). This was adapted from a skin care protocol published by The University of Worcester in 2021 (Hobday, 2021). This was the result of a Macmillan Cancer support grant to undertake a literature review, which was originally suggested by The National Lymphoedema Partnership (NLP).
The review took place between 2017 and 2019. The review found many publications stating the importance of skin care; however, only a few offered suggestions on daily management that went beyond advising that care should be daily and meticulous, and tips on how to look out for signs of infection. With no criticism of these publications, the NLP members discussed the need for a standard protocol on which skin care guidelines could be based, added to, and refined, as research became available. All agreed that there was a need to create a protocol that gave actual advice.
It is against this background that the skin care protocol, was produced (Table 1). There was considerable consensus sought from the expertise among those caring for patients with lymphoedema. The protocol should be adapted and added to, depending on the individual patient's needs and assessment. Helping to form part of a comprehensive self-management strategy or the basis of literature and care for service provision, the protocol offers a starting point on which to build further advice and, may especially help those HCPs setting up new services.
Table 1: Standard skin care protocol
| Action | Protocol |
|---|---|
| Examine | Conduct a thorough examination of the limb, look ing for signs of changes in the skin condition; for example: increased dryness; infection; injury; differences in shape resulting from alterations in the distribution of oedema. While conducting the examination, use your hands to feel for any increase in temperature, which may indicate an infection |
| Wash | Use warm water and a soap substitute such as aqueous cream. Soap substitutes are water- and oil-based, and therefore, do not have the same irritant or drying effect as perfumed soaps do. Aqueous cream is 70% water. Great care must be taken when washing and drying between the fingers. Consider using a spray cleanser if soap and water are not available |
| Moisturise | Apply moisturiser at least once a day; preferably twice, if clothing does not make this difficult. Putting clothing back on will be easier if patients wait for up to half an hour after applying cream, as this will allow time for the preparation to be absorbed (Note: the main aim of a moisturiser is to stop the evaporation of water from the skin). If the limb has the presence of hair, make sure the hair is returned to its natural position, thus avoiding tension on the hair follicle, leaving it exposed. Moisturising at night, once compression garments are removed, is essential |
| Avoid skin damage | Protecting the integrity of the skin will reduce the chance of infection. Historically, patients were advised not to let a medical practitioner take blood or give an injection into the affected limb. There is little robust evidence to support this; however, it is known that any break in the surface of the skin creates an opportunity for bacteria to enter the tissues and thus, the possibility of infection. Anecdotally, infection is reported by patients to be associated with the onset of a latent oedema. It is therefore recommended to take all reasonable precautions to avoid any puncture wounds. Great care should be taken when working in the garden to avoid cuts and insect bites. All cuts should be treated with an antiseptic solution, including preparations such as diluted tea tree oil |
| Remove unwanted hair | The aim is to remove hair above the hair follicle, not extract the hair from the follicle and leave it exposed as a portal for infection. As such, plucking, waxing and shaving should be avoided. The use of an electric razor or depilatory cream is recommended |
Note: Intellectual property remains with University of Worcester, but permission to reproduce with acknowledgement, is granted.
Patients should be encouraged to carry out skin care twice daily and follow the protocol as described in Table 1.
So why is skin care so important for those at risk or have lymphoedema?
Chronic inflammation associated with lymphoedema results in an increase in the production of fibrosis and fat deposition, which then contributes to the hardening of the skin. This results in change of oedema, converting from pitting to non-pitting. Furthermore, this leads to the reduction in the flow of lymph. The resulting changes have an effect on the skin and subcutaneous tissues and therefore, there is a need for skin care as part of any management of lymphoedema. As such, the importance of skin care cannot be under-estimated.
Skin complications associated with lymphoedema are described as common. Such complications will vary according to the severity of the impaired lymph drainage and the degree of increased lymph load (e.g., venous hypertension). The aim of appropriate skin care is fundamentally to keep the skin healthy and reduce the incidence of complications, such as infection. HCPs should consider aesthetic factors from the patient's point of view. Skin care practices are life long and as such, must be part of the individual's self-care regime. This is central to successful lymphoedema management.
Conclusion
A standard approach to skin care has been presented in this commentary, citing a protocol on which to build patient care. It is by no means exhaustive, but serves to present some consensus in an area of healthcare, where there is a still a dearth in research.