Lymphoedema and chronic oedema are common conditions seen in community caseloads. Skin care is a frequent and crucial requirement in aiding the patient to feel comfortable, prevent infection, manage fluid excretions and assist with pain management. It is one of the cornerstones of care for those with lymphoedema/chronic oedema, in addition to compression therapy, exercise and manual lymphatic drainage. Crucially, the skin integrity needs to be maintained to the best possible extent to avoid breakdown of the skin. Community nurses play a vital role in skin care for those with lymphoedema/chronic oedema, and this article provides an up-to-date recap of the important things to remember when caring for the skin of someone who has chronic oedema or lymphedema.
The skin is a barrier to infection, and care of this barrier is, therefore, an integral part of lymphoedema and chronic oedema management. The British Lymphology Society (BLS) (2017) stated that infection can trigger lymphoedema, so preventing infection through good skin care is vital. The the skin should be washed daily with non-perfumed soap, kept well moisturised, protected from sunburn and treated for insect bites promptly using antihistamines (BLS, 2017). Correct footwear should be used to avoid abrasions, and regular checks should be conducted for skin folds and between toes for fungal infections. Cuts or scratches would need antiseptic treatment, and the GP should be contacted if the area is inflamed; where there are signs of cellulitis, this should be treated as quickly as possible (BLS, 2017). Without managing these areas, untreated skin tears and breaks can introduce infection and possible sepsis, with wounds that are extremely difficult to heal and require extensive community or hospital management on some occasions, potentially causing deterioration of the patient's physical and mental health, as well as costing the NHS a vast amount of money (BLS, 2017).
Lymphoedema Scotland (2020) stated that skin care is important to reduce the risk of developing cellulitis and to maintain skin integrity so that the skin is soft and supple. Preventing the skin from becoming dry and cracked is advised, through daily skin care, involving observation, cleansing and moisturising, with the routine in place being tailored to the individual's needs. The advice for lymphoedema is very similar to that for chronic oedema when it comes to skin care regimens.
Marie Curie (2021) advised on the importance of avoiding any cuts or scratches, because these can allow the entry of bacteria under the skin, which can cause cellulitis (Figure 1), which would then mostly require treatment with antibiotics. Signs of cellulitis include redness of the skin, warm temperature/hot to touch, increase in swelling and pain around the affected area. Therefore, it is of vital importance that observations are made when carrying out the patient's skin care regimen, in order to treat cellulitis as soon as possible. If cellulitis is suspected, it is imporant that the patient has timely access to antibiotics, so the GP, or case manager, independent nurse prescriber or district nurse should be contacted.
Figure 1. Cellulitis on the ankle of a patient
When carrying out the daily regimen, especially if it is new to the patient, the care plan should be examined. The care plan should clearly define how to take care of the patient's skin, which will likely include diagrams and measurements of the legs and other affected areas, so that fluid buildup can be monitored in line with the level of bandaging that may be in place, along with any wounds in situ and individual dressing requirements. This would usually be carried out by a specialist wound care/lymphoedema nurse. Skin care for would involve regularly washing the skin with gentle soap and water, drying the skin thoroughly afterwards to prevent skin breakdown, daily moisturising using emollients and keeping the skin dry in the case that there is any leakage of fluid, known as lymphorrhoea (Marie Curie, 2021). Cannulation, blood pressure monitoring and venipuncture should be avoided on the affected limb, as any break in the skin can create a route for bacterial entry and lead to cellulitis.
A complication of either lymphoedema or chronic oedema is ascites-that is, fluid build-up in the abdomen. It can occur when fluid is not being drained from the tissues into the circulatory system properly, perhaps because the circulatory system is failing, or because of blockage caused by a tumour, for example. It is useful to be aware of which conditions ascites may occur in. Most commonly, conditions such as cancer, specifically ovarian cancer, heart failure, renal failure and liver failure may result in a patient being more at risk of ascites. This complication should be examined for on the visit for skin care. Symptoms to examine the patient for include pain and discomfort in the abdomen, swelling around the abdomen, problems sitting upright, nausea and vomiting, loss of appetite, acid reflux, constipation and breathlessness (Marie Curie, 2021).
Where ascites in suspected, a senior health professional should be contacted as soon as possible so that the condition can be managed promptly and the treatment is more likely to be effective. The district nurse may manage the wound alongside tissue viability nurses, and an indwelling drain may be required, so the fluid can be drained in the patient's home by the nurses. When caring for the patient with suspected ascites, it is important to:
- Find the most comfortable positions for them to sit or lie in
- Prevent pressure ulcers by providing good skin care
- Support mobility
- Advise on short periods of exercise with a lot of rest in between
- Manage pain
- Report sudden swelling with urgency
- Monitor for signs of infection
- Monitor for signs of breathlessness as fluid buildup may cause abdominal pressure against the lungs (Marie Curie, 2021).
Particular skin problems that can occur in chronic oedema or lymphedema include dermatitis and eczema, characterised by red, itchy and weeping skin. This condition can cause scratching, which, in turn, leads to breaks, which are difficult to heal and prone to infection (Marie Curie, 2021). The eczema may be due to allergens and can, therefore, be avoided by use of unscented emollients, reducing the risk of allergic reaction. Fungal infections are also common in oedematous skin, and, where untreated, can cause cellulitis. Fungal infections between the toes are important to flag up to the patient's GP and skin specialists, so that the correct anti-fungal treatment can be prescribed. Lymphorrhoea is a term to describe leakage of lymph fluid through the skin surface, which can occur if the limb swells suddenly. Sudden swelling can lead to skin breakage if the skin is not kept soft and supple, or where the skin becomes thin and fragile. The risk of infection increases where lymphorrhoea is present, and the best treatment should, therefore, be sought from specialists in a scenario where a nurse detects lymphorrhoea (Marie Curie, 2021).
For lymphoedema patients, specific type of skin treatments are recommended, as described by Fife et al (2017). The authors recommended topical agents containing lactic acid, urea, ceramides, glycerin, dimethicone, olive fruit oil or salicylic acid for hyperkeratotic skin desquamation. Salicylic acid is a keratolytic agent that may improve the penetration of other topical agents through the skin. Patients with lymphoedema patient may be at risk of lymphangitis (an infection of the lymph vessels), which necessitates immediate contact with the specialist, GP or case manager. Lymphangitis attacks present on a recurrent basis, usually lasting from 4 to 7 days. They can occur are up to four times a year, depending on the severity of the lymphoedema.
Topical steroids may be required for chronic oedema and lymphoedema, which are the mainstay of treatment for inflammatory dermatoses, such as dermatitis, which can be common in these patients. Patients with recurrent lymphangitis and systemic signs of infection may also require long-term prophylactic systemic antibiotics in order to reduce infectious episodes (Fife et al, 2017).
In reducing the chances of infection and its various causes in patients with chronic oedema, good hygiene daily is important, with careful washing. Soaps dry out the skin; therefore, moisturising soap substitutes are recommended to a more independent patient or for use by the nurse on the daily visit. Avoidance of skin damage or trauma protection from sunburn, cuts, insect bites, injections and hot water would involve the use of appropriate shoes for patients with lower extremity lymphoedema and gloves for certain activities involving affected upper extremities, for example, gardening (Fife et al, 2017). If the patient wants to shave, it is recommended they use an electric razor, so that skin trauma can be avoided.
The best thing for the skin as part of the daily routine would be the applications of non-perfumed emollients, so that the epidermis can be aided to retain water and reduce water loss. Regular use of ceramide-containing emollients can help to reestablish the skin's protective lipid layer, which helps to prevent water loss. These products are available as either lotions (oil and water preparations that usually have more water than oil and, thus, have a short-lived effect) or creams (oil-in-water or water-in-oil emulsions) (Fife et al, 2017). Creams are recommended as the first choice for dry skin. A word of caution is to be aware that emollients may damage the elasticity of compression garments; therefore, recommendations include avoiding applying the emollient immediately before putting on hosiery. Topical steroids, antifungals and antimicrobials have been successfully used off-label for the conditions associated with lymphoedema (Fife et al, 2017), including tazarotene gel 0.1%. Tacrolimus in topical formulation has been suggested for off-label use with severe stasis dermatitis as a possible alternative to topical steroids.
Nail hygiene is another factor that should be kept in mind, as a large volume of bacteria can be harboured under the nails. Therefore, this should be an integral part of the skin care process; the patient should be reminded to regularly wash their hands thoroughly and they should be shown how to clean the nails effectively.
Conclusion
Overall, skin care is a crucial part of nursing care of patients who have chronic oedema and lymphoedema. It is important to have a daily regimen set up in a care plan, with the involvement of tissue viability nurses and district nurses, as well as regular contact with the patient's GP. Because of the nature of the skin in these conditions, where there is substantial fluid beneath, the skin is prone to cellulitis and allergic dermatitis, which should be monitored for and avoided, for example, by using the correct unscented skin care products, such as emollients, maintaining skin hygiene and keeping the skin soft and supple with the preparations set out in the regimen. Steroidal cream may be required along with certain dressings, as recommended by the specialist, if the patient develops skin breaks. Skin breaks are very hard to heal so should be avoided at all costs, with infection prevented by good nail hygiene and protective clothing. Prior to applying compression therapy, it is important to remember that compression products may be adversely affected if put straight on after the emollient, as the emollient can damage their elasticity.
KEY POINTS
- Skin care is one of the cornerstones of management for chronic oedema and lymphoedema, along with compression therapy, manual lymphatic drainage and exercise
- Daily skin care may be assisted by nurses or partly managed by the patient
- Emollients protect the skin from water loss and prevent skin breaks
- Skin breaks should be avoided as they can take a very long time to heal, and increase chances of infection (cellulitis)
- The patient's care plan should be followed when administering skin care
CPD REFLECTIVE QUESTIONS
- What are the signs of cellulitis that you might observe in a patient with chronic oedema/lymphoedema?
- Why is skin care important for those with chronic oedema/lymphoedema?
- Why must care plans be individually tailored to the patient's needs?