Lymphoedema affects approximately 200 000 people in the UK (NHS England, 2024), and many readers will have nursed patients with it and even seen people with it in their daily lives. Unlike leg ulcers, lymphoedema does not heal and currently has no cure (Wong and Furniss, 2020).
Its physical symptoms have a severe impact on a patient's psychological health and wellbeing; yet, there is so much that can be done to ease and manage these symptoms and improve a patient's quality of life. With the availability of compression wraps, a patient and/or their carer can manage their lymphoedema themselves and can gain so much more control over their lives. Initially, this may require input from a district nursing team, but this input can be soon replaced with self-care and improvement in a patient's life.
What is the lymphatic system?
It is a complicated system that drains out fluid from the body's tissues and returns it back into the circulator system. It is a passive system, relying on the body's own movements to drive it and to return this fluid.
Initial lymphatics are made up of a single layer of endothelial cells, the cells that also line blood vessels, which occupy the spaces between tissues and are anchored to the skin and muscles by fine filaments. As the skin and muscles stretch and contract, with the body's movements and especially limb movements, the fine filaments open and close the initial lymphatics, drawing fluid along them. The fluid is sent to collecting vessels; from there, it is moved into the lymph nodes and eventually back into the circulatory system (Lee and Lawrance, 2017).
The lymphatic system is a passive system, it does not have any muscles or tissues acting directly on its vessels. Therefore, a person's movement and exercise powers it (Lee and Lawrance, 2017).
It also products lymphocytes—the white blood cells that attack invading microorganisms and cancer cells—an important part of the body's immune system (Lee and Lawrance, 2017).
What is lymphoedema?
When the lymphatic system fails to drain fluid from the body's tissues, it causes the tissues to swell with excess fluid (Hopkins, 2008). It most commonly affects the limbs, but it can also affect other parts of the body, depending on where the lymphatic system has been damaged or is impaired (Wong and Furniss, 2020). The swelling needs to be present for longer than 3 months for it to be consider lymphoedema (Everett et al, 2020).
Lymphoedema is divided into two categories:
- Primary, which is rare and found mostly in children
- Secondary, which is caused by trauma and/or damaged to the lymphatic system (Box 1) (Wong and Furniss, 2020).
Box 1.Causes of secondary lymphoedema. Adapted from Wong and Furniss (2020)
- Cancer treatment – damage to the lymph nodes from radiotherapy or surgical removal
- Infection
- Trauma to the affected limb
- Surgery, especially orthopaedic surgery to a limb
- Obesity – a body mass index >50 kg/m.
Lymphoedema will worsen with age (Wong and Furniss, 2020). Brown (2019) found its incidence doubled in those aged over 85 years, when compared with those aged 65–74 years. Both types of lymphoedema can be managed but cannot be cured (Brown 2019).
Pugh et al (2018) have recommended that a patient is referred to a specialist lymphoedema service for a diagnosis and treatment plan. They can advise the patient on self-management and help put together a treatment plan. However, a patient also needs assessment for lymphoedema management, especially where limb compression is involved. This will include ruling out other causes of swelling, such as:
- Cellulitis
- Ankle brachial pressure index of <0.8 or >1.2
- Unstable cardiac failure
- Deep vein thrombosis (Hopkins, 2008).
What are the complications?
The most commonly identified complications of lymphoedema include:
- Swelling
- Skin integrity
- Excessive exudate (sometimes called leaking legs)
- Infection, especially cellulitis
- Wounds
- Reduced mobility, especially from the weight of the effected limb
- Psychological effects
- Social isolation (Wigg and Lee, 2014; Pugh et al, 2018; Todd, 2018).
How to manage these complications?
Compression
Compression is the ‘gold standard’ for the management of both lymphoedema and venous ulceration (Brown, 2019). It works by applying pressure to the affected limb in the form of compression, in order to force fluid out of the tissue and back into circulation (Brown, 2019). However, lymphoedema requires a higher pressure to return the fluid from the limb's tissues. For venous disease, a leg will require at least 40 mmHg of pressure, while for the reduction of lymphoedema it can take up to 60 mmHg of pressure (Phillips and Wright, 2024).
Wigg and Lee (2013) have recommended the use of multi-layer lymphoedema bandaging to manage patients with extreme shape deformity, where there are wounds, lymphorrhea (leaking legs) or skins problems. They recommend that multi-layer bandaging is applied daily for 2–3 weeks, with daily skincare and manual lymphatic drainage (a specialised massage technique). This is a very time-consuming and resource-heavy activity. Nurses have to be suitably trained and competent in this banding technique (Hopkins, 2008), which is different to compression bandaging for venous ulceration and involves bandaging the whole leg, from toes to top of the thigh. Manual lymphatic drainage is also a specialist skill. The author, in his clinical practice, performed multi-layer bandaging (without manual lymphatic drainage) and can confirm it is very time-consuming and, for a considerable amount of it, he was the only nurse in his team competent in it.
Traditionally, compression garments have been used to reduce lymphoedema (Pugh et al, 2018). Patients can find well-fitting compression garments may be difficult to apply, which can lead to the patient not using them. In Patullo's (2017) case study, the patient had stopped using compression hosiery because he struggled to apply them. Exaggerated skin folds, in addition to lymphoedema, can cause compression hosiery to gather and cause a tourniquet at that site (Todd, 2018). Difficulty donning and duffing compression hosiery can increase the risk of skin damaged (Pugh et al, 2018). They will need to be removed daily to allow skin care.
Now there is an alternative in the form of compression wraps, such as the circaid® juxtacures® and circaid® juxtafit® from medi UK, the Jobst® FarrowWrap®, and the ReadyWrap® adjustable compression garments from Lohmann and Rauscher® (Williams, 2016). They are made from inelastic fabric, which is wrapped around the limb and secured in place by strips of Velcro. At the back of the limb, they are stitched or secured into a single garment, aiding ease of application (Brown, 2019). Applying these wraps does not require specialist training as compression bandaging does, and allows patients to self-apply them. They allow patients and/or their carers to adjust the wraps, to tighten them during the day as the swelling eases. It also means they can be easily removed and reapplied for daily skin care.
Wigg and Lee (2013) found that multi-layer lymphoedema bandaging can slip and become uncomfortable after 24 hours of application because of the reduction in the limb size, from the banding working on the lymphoedema swelling, which usually occurs within the first 2 hours. Wigg and Lee (2013) recommend that compression wraps can be used as an alternative. They do not need specialised training to safely apply them – the patient and/or their carers can apply them, reducing the need for nurse visits, and the patient and/or carer can adjust them, especially when they become lose.
Phillips and Wright (2024), from their study, found that wraps made from double-layer material provided greater mean pressure than those made from single-layer material. They recommend using double-layer wraps for lymphoedema management because of the higher compression pressures required.
The evidence for the success of compression wraps is usually anecdotal. Many nurses have used them in practice (including this author) and found them clinically beneficial, but there is not a lot of clinical evidence to support this. Phillips and Wright's (2024) study compared seven different wraps. However, they did not compare the wraps to any other compression method. Williams (2016) conducted a review of the evidence for using wraps. They found that wraps are effective but the evidence is very limited; a large number of papers on the subject being single patient case studies, with little evidence for their cost-effectiveness. Thomas (2017), in their literature review, found the same problem with the evidence for the use of wraps. They found no evidence that the use of wraps is more expensive that other forms of compression therapy, though wraps do require a significant initial cost.
Skin care
Cellulitis is one of the main complications of chronic lymphoedema (Todd, 2018). It is a bacterial infection of the subcutaneous tissue, commonly caused by group A streptococcus, and can be very uncomfortable (Pugh et al, 2018). A skin care regime should focus on skin integrity to reduce the risk of cellulitis.
The affected limb should be washed, dried and moisturised daily. A pH-neutral skin cleanser should always be used because of the dehydrating affect soap can have on the skin (Stephen-Haynes and Stephens, 2013). Skin on a swollen limb is already under strain, so daily skin cleaning should not damage it further. Skin should always be patted dry and not rubbed, to again reduce risk of damaging it. Emollients used daily can moisturise skin (Stephen-Haynes and Stephens, 2013), restoring lost moisture and helping to maintain the skin's elasticity, flexibility and barrier function, as well as combating dry skin.
Lymphoedema does not always cause uniform swelling to a patient's limb. It can cause exaggerated skin folds, providing an ideal environment for fungal or bacterial infection (Pugh et al, 2018). Therefore, special care should be taken to clean and dry these areas.
In order to prevent cellulitis, patients should avoid skin cuts and breaks. Therefore, the patient and/or their carer should be encouraged to perform daily skincare and to observe for any abnormal skin changes, wounds and signs of cellulitis.
Lymphoedema can cause changes to the skin in the form of hyperkeratosis and papillomatosis (Todd, 2018). Patients need to beware that these changes can occur. Hyperkeratosis causes the skin to thicken and appear scaly (Figure 1). Papillomatosis are small lumps or bumps on the skin, that can be mistaken for warts (Figure 2). Both of these can make patients feel like their limbs look ‘dirty’ (Todd, 2018).
Managing exudate
Lymphorrhoea—fluid leaking from a swollen limb, often called ‘leaking legs’—can be a complication from lymphoedema. Though it does not affect all patients with lymphoedema, it can be very distressing for patients when it does occur (Pugh et al, 2018). It presents as a clear or straw-coloured watery fluid that oozes from the skin (Pugh et al, 2018). If left unmanaged, this fluid will cause moisture-related skin damage, maceration, which will further impair skin integrity (Pugh et al, 2018).
Compression therapy will manage and relieve lymphorrhoea (Pugh et al, 2018). Lymphorrhoea is excessive fluid oozing out of the skin; therefore, compression will return this fluid back into the circularly system. Compression may not achieve this straight away, so the patient may have to use absorbent dressings under their compression, to absorb the lymphorrhoea until it stops. This will have to be a dressing that can be used under compression, such as 3M™ Kerramax Care™, which locks away the moisture in its core.
Wound care
Superficial ulceration can occur with swelling from lymphoedema but especially if the patient is experiencing lymphorrhoea, from the skin damage maceration.
The first treatment for these wounds is compression (Pugh et al, 2018). This eases the swelling and lymphorrhoea of the affected area, aiding skin integrity. If the patient is experiencing lymphorrhoea then it is important to use absorbent dressings under the compression because excessive exudate can damage wound beds and affect healing (Todd, 2018).
For the wound itself, consider what type of dressing will be suitable for that wound, which dressing with encourage granulation of its wound bed. There are a lot of different dressing available and readers will have a lot of experience in their usage. But remember, it will have to be a dressing used under compression, so it should not be too bulky.
Exercise
The lymphatic system is a passive system and it is powered by the body's own movement. Lymphoedema can increase any mobility problems due to the extra weight from the swollen limb(s) (Todd, 2018). The weight alone from a grossly swollen limb(s) can reduce a patient's mobility.
Exercise is very important in the self-management of lymphoedema; it increases the pumping action of muscles, encourages venous and lymphatic drainage and helps to maintain or improve range of movement (Wigg and Lee, 2014). Therefore, patients should be encouraged to exercise as much as possible. Social prescribing schemes can be accessed through a patient's GP practice (NHS England, 2020). Many of these offer access to exercise classes or programmes. This will provide a patient with regular exercise but there will be a social element too – exercising with other people, who can also help encourage the patient to keep exercising.
Furthermore, patients should be encouraged to elevate the affected limb(s), if seated for any length of time, to help prevent any dependent oedema (Pugh et al, 2018).
Weight loss
A body mass index greater than 50 kg/m2 is a risk factor for lymphoedema (Wong and Furniss, 2020). Being overweight can put a strain on the lymphatic system; it can also reduce a patient's mobility. In their audit, Todd et al (2017) found that 92% of patients with oedema were also overweight. Losing weight will aid a patient to manage their own lymphoedema, help them exercise, help their mobility and help reduce swelling (Todd, 2018).
Again, social prescribing schemes (NHS England, 2020) can be helpful here. Many of them have access to weight lose services, such as individual coaching or group support services. These can give patients psychological support with weight loss.
Psychological support
Lymphoedema can have a negative impact on a patient's wellbeing (Todd, 2018). Swollen and distorted limb(s), the excessive weight of the limb(s) and changes to the skin of that limb(s) can all seriously impact on a patient's body image. Patients have found skin changes, such as hyperkeratosis and papillomatosis, make their skin look ‘dirty’ (Todd, 2018). Lymphorrhoea will wet and stain clothing and bedding (Todd, 2018). All these can lead to marginalisation, social isolation and can affect a patient's employment, especially if their work environment is unsupportive (Todd, 2018). Nurses should be aware of these factors too.
There are also charities such as the Lymphoedema Support Network, which provide education and support to patients with lymphoedema, including a telephone helpline. Further information can be found at: https://www.lymphoedema.org/.
Social prescribing schemes (NHS England, 2020) can also help here. Many of them provide access to socialising groups, such as gardening, cooking classes, book groups, where a patient can socialise with others. These groups can provide an avenue where a patient can socialise in a safe and supportive environment.
Diuretics
Pugh et al (2018) have warned against use of diuretics in lymphoedema; they state, ‘Put simply, diuretics work on kidneys, not on legs.’ Diuretics work, to varying effects, on the kidneys, making them work harder to increase a patient's fluid output, but they have no effect on the lymphatic system. They can have a negative impact on a patient's quality of life, with an increased frequency of micturition, which may cause a patient to not leave their home for fear of soiling themselves (Pugh et al, 2018).
Preventing reoccurrence
Skin care, exercise and compression garments are the components of essential care for lymphoedema. These three combined, as appropriate for the patient, will provide the maintenance therapy where a patient can manage their lymphoedema (Wigg and Lee, 2014).
Daily skin care will maintain skin integrity and help prevent cellulitis and wounds development. Exercise will help power lymphatic drainage, helping to reduce swelling. Compression will aid lymphatic drainage, forcing fluid out of the tissue and back into circulation.
If the suitable compression garment is used, then a patient and/or their carers can achieve their own management. However, it must be the right compression garment because an ill-fitting garment is not fit for purpose if a patient is not able to apply it daily (Pugh et al, 2018).
Conclusion
There is no cure for lymphoedema (Wong and Furniss, 2020) but there is a lot that can be done to manage it and prevent its complications. A patient and/or their care can manage most of these interventions themselves, with minimum support, but it must be the right intervention for them. Good lymphoedema management can help reduce the psychological impact of living with this chronic condition. Like all healthcare, good lymphoedema management requires person-centred care, but can generate such positive results.
Key points
- Lymphoedema is not curable but is manageable
- When the lymphatic system fails to drain fluid, the swelling caused is lymphoedema
- Compression is the ‘gold standard’ for the management of lymphoedema
- Daily skin care will support skin integrity
- Exercise will help reduce lymphoedema.
CPD reflective questions
- What are the benefits of the lymphatic system?
- What types of compression can be used with lymphoedema?
- Why will exercise aid the reduction of lymphoedema?
- What is the main consideration for choosing a dressing for a superficial ulcer caused by lymphoedema?