Article by Maisie Hillman. To remain healthy, it is vital for anyone with lymphoedema to understand the role good skin care management plays. This provides guidance and helpful tips on what those with lymphoedema can do to keep their skin in tip top condition.
Lymphoedema is caused by an accumulation of high protein fluid in the soft tissues, which results in the swelling of the affected limb or area/s.
Lymphoedema is characterized as primary or secondary based on the pathogenesis. Primary – which results from a genetic abnormality of the lymphatic system. Or secondary – resulting from injury, including a non-accidental injury, obesity, poor venous function or following treatments such as radiotherapy and/or surgery of removal of lymph nodes and is the more common form of the two.
Lymphatic insufficiency may cause swelling of one or more limbs or other areas of the body such as the breast, neck and head or genital regions.
There are four cornerstones to aid for individuals with lymphoedema. Skin care is the one being discussed in this article; however, it is important to add the other three as they are all to be used in conjunction. Compression (bandages or compression garments), manual lymphatic drainage massage (MLD) along with self-lymphatic drainage massage (SLD) and some exercises which are referred from specialists are the other three cornerstones.
There is high importance of introducing and maintaining skin care management to individuals with lymphoedema as it may lead to significant unwanted changes within the skin.
As prolonged fluid stasis occurs in chronic lymphoedema, substances that penetrate the skin accumulate with lymph fluid in the tissues. This triggers a progressive, chronic inflammation and accumulation of fibroblasts, adipocytes, and keratinocytes.
The macrophage activity is reduced and an overgrowth of interstitial connective tissue manifests. Therefore, swelling resulting of lymphatic insufficiency and without ongoing lymphoedema management, pathological changes in the skin such as thickening, hyperkeratosis, papillomatosis, and deepening in the skin folds can occur.
Hyperkeratosis – results from the thickening of the stratum corneum. The visual representation is that of a thick, waxy, scaling looking skin and can vary in colour from yellow to brown. It can affect the whole limb or just a small patch.
Papillomatosis – blind-ended superficial lymphatic vessels swell due to back pressure and protrude through the skin – cobblestone appearance.
Enhanced skin folds – Are caused by overstretching of the skin due to oedema. The condition also predisposes the skin to become dry and undernourished as the skin is dealing with alterations to the stratum corneum leading to a loss of water, lipids, or the natural moisturising factor of the epidermis.
The skin is further being stretched and there is reduction of oil secretion by the sebaceous glands. Drying and cracking of the skin may allow a potential point of entry for bacteria, therefore more likely to get infections and ulcerations.
The aim of skin care management for those with lymphoedema is for optimizing skin and tissue condition, maintain skin integrity, treat skin complications caused by lymphoedema and to prevent or reduce risks of infections, specifically cellulitis. Since the swollen limb has static protein rich fluid, it makes the patient prone to infection/s, which can further lead to further fibrosis and scarring of the lymphatics.
With visual observation being number one to detect skin changes, ultrasound (diagnostic imaging) , palpation of the skin and stemmer’s sign are further good common assessments of the skin in the affected limb/s. palpation aids to detect heat if chronic inflammation or infection has occurred. A stemmer’s sign, where the tissue at the base of the second toe cannot be pinched is used to detect the skins elasticity that progressively occurs in lymphoedema. If the stemmer sign is positive, it indicates epidermal remodelling due to fluid stasis within the tissues,
It is highly encouraged to do a skin inspection daily to look for skin breaks, cuts and any signs of infections and performing daily skin hygiene is a well-recognised strategy to prevent any infections and reporting these to a clinician for early management.
Your daily skin hygiene should include:
Cleaning the skin from pathogenic organisms, dust, and dirt on a daily basis to reduce risks of infections.
- Keeping the skin clean with daily cleansing with a mild, pH balanced, soap-free cleanser (if skin folds are present, pay particular attention to these)
- Avoid using soaps as they alter the natural pH of the skin and remove the protective sebum layer.
- To dry the skin by using a gentle and patting motion.
- If skin folds are present, ensuring that they are clean and dry.
Regular application of moisturisers on the skin assists in replacing the skins lost sebum and encouraging moisture retention by the skin. Emollient agents for lymphoedema are beneficial as they provide a surface lipid layer on top of the epidermis, which traps and conserves water within the skin to prevent it drying out.
- Moisturise using an emollient to replace lost sebum and encourage moisture retention, also applying once a day unless skin is very dry or hyperkeratotic, then twice a day is more appropriate. Sorbeline with vitamin E is considered to be a good choice and emollients with greater oil content.
- Emollients can be gel based (e.g. double based gels), cream based, and ointment based.
- Apply the products in downward strokes to avoid folliculitis – an inflammation of the hair follicles.
- Avoiding scented/perfumed products as they can be skin sensitizers.
- Treat scratches and abrasions with an antiseptic until healed and refer to a specialist.
- Avoiding sunburn – As this requires healing and repair, the body achieves this by increasing blood flow to the area which causes increased capillary filtration and a subsequent rise in interstitial fluid. Therefore, in someone with lymphoedema, this may overload a compromised lymphatic system and may induce limb swelling.
- Skin trauma prevention – Use SPF50, appropriate and safe methods of shaving, and using protective equipment for daily living activities such as gardening gloves, insect repellents, suitable footwear and clothing while performing outdoor activities, not wearing tight jewellery.
- Assisting needs to be provided to individuals with lymphoedema who are experiencing problems (e.g. motivational, physical limitations, financial) carrying out the required care.
If injuries do occur
- Cleanse with water, dry thoroughly and cover with an adhesive dressing.
- Watch the skins progression to healing.
- Responding to any sign of infections by seeking medical attention.
Approximately one third of individuals with lymphoedema can experience cellulitis from infections and other factors. Because the skin acts as a barrier and is the first line in physical, chemical, and immune defence between the internal organs and the external environment, it is crucial that its integrity and functionality is maintained.
Therefore, caring for the skin by reducing the oedema and preventing dryness and injuries are crucial strategies to prevent inflammation, further skin changes and infections.
About Maisie Hillman
Maisie is currently studying the Bachelor of Health Sciences: Dermal Science at Victoria University in Melbourne. She believes that lymphoedema is a significant but largely an unrecognised condition and hopes this article on skin care management is a helpful resource for those with the condition.
General Advice Warning: This blog is not designed to replace professional advice. It has been prepared without taking into account your medical situation or needs. You should consider the appropriateness of the advice, in light of your own health objectives and needs before making any decision as to what is appropriate for you.