by Aletha Tippett MD
By Alton R. Johnson Jr, DPM
Four weeks ago, I was granted the privilege to treat a patient with type 2 diabetes with neuropathy who presented to the wound care center after developing a full-thickness pressure ulceration on the lateral aspect of her right leg as a result of an ill-fitted brace used four weeks earlier. The first clinical feature I noticed about the patient's lower extremity compared with the previous encounter was marked increased pitting edema. As a sequela of the lack of compression, the patient's lower extremity edema had increased, causing the wound to break down further in comparison with our last encounter with her. I first asked the patient why she discontinued the multipurpose tubular bandage that was dispensed and applied to her right extremity during the last visit. Her immediate response was that the home health aide had disposed of it by mistake; however, the patient stated that the aide used an available non-compressive stockinette instead. It was at this moment that I realized I identified the precise topic for my introductory WoundSource blog entry.
Diagnosis of Lymphedema
One of the most overlooked types of swelling is lymphedema. As wound care specialists, we often treat every edematous limb as though it were affected by venous insufficiency. Not all edema is attributed to venous insufficiency, although the most common cause of secondary lymphedema is chronic venous insufficiency, also known as phlebolymphedema.1 Essentially, prolonged venous insufficiency can lead to lymphedema in a patient's lower extremities.
One quick way of clinically diagnosing whether a patient has lymphedema is evaluating for Stemmer's sign. Testing for Stemmer's sign requires the patient to be lying in the supine position. The clinician then examines for a thickened fold of skin at the base of the second toe (for lower extremity swelling) or second finger (for upper extremity swelling) while gently pinching and lifting the skin. A positive Stemmer's sign is revealed if the skin that has been pinched cannot be brought together.
Of course, if clinical appreciation is not enough, the clinician can always perform lymphoscintigraphy or indocyanine green near-infrared fluorescence lymphatic imaging for further evaluation. These imaging modalities will aid in specifically identifying any malfunction within the patient's lymphatic system. Lymphedema can often be confused with lipedema. However, one of the most effective determinants of lipedema is that the "swelling" appearance actually represents excessive deposits of subcutaneous fatty tissue, and the feet are most often spared.
Treatment of Lymphedema
The gold standard for treating lymphedema remains complete decongestive therapy, which is an intensive therapeutic regimen consisting of manual lymphatic drainage (massage), compression therapy, exercise, and skin care. There are various types of compression bandages and devices that can be used to treat lymphedema, such as multilayer wraps, pneumatic compression pumps, compression garments, and the less popular kinesiology tape method. I find kinesiology taping highly useful in patients who need a long treatment regimen for lymphedema control because it does not require frequent office or home visits. Typically, a single application of high-quality kinesiology tape can last approximately five to seven days. Kinesiology tape works by lifting the epidermis and thereby allowing the superficial lymphatic channels in the affected areas to open. This method also allows the clinician to guide the desired directional pull of the lymphatic fluid drainage based on application.
Compression of the lower extremity for wound healing is still an underused and underappreciated dressing modality. I am not stating this from a statistical standpoint but rather from a clinical standpoint. The reason is as illustrated in my patient encounter: compression is not just another layer of dressing applied to keep the underlying dressing intact and protected. Compression is as important as the wound bed dressings that are applied to the patient's ulceration. The best analogy is that compression is similar to support beams on a bridge. If compression is not present to support the chronic ulcer to heal, then no matter how sophisticated the wound bed dressing is it will not be able to function at its full capacity, thus prolonging healing.
This occurs particularly in patients with lymphedema when the extremity is not compressed because the wound has been exposed to increased numbers of dead cells, bacteria, endotoxins, and matrix metalloproteinases. All of these factors will make it even more challenging for the body to do its job during the proliferative and remodeling phases of wound healing. By providing adequate compression, this lymphatic fluid can be removed from the ulceration and return back to the lymphatic system. This process allows the ulceration to be in the best state to heal fully. Even after the ulceration is healed, it must be emphasized to the patient that lifelong compression modalities will be required to maintain proper lymphatic function.
When faced with chronic ulcerations in the presence of edema, it is our duty as wound care specialists to be able to understand that not all swelling of the extremities is venous driven. In addition, we have to advocate to our patients that compliance with compression therapy is vital to their wound healing and/or wound recurrence. As for the patient I referenced earlier, she was able to obtain the proper compression stockinette; now the edema is well controlled, and the wound has reduced significantly in size, with a healthy wound bed ready for grafting. Even the most elementary treatment can make the difference in saving a limb and life.
1. Stout NL, Weiss R, Feldman JL, et al. A systematic review of care delivery models and economic analyses in lymphedema: health policy impact. Lymphology. 2013;46:27-41.
About the Author
Alton R. Johnson Jr., DPM is currently an American College of Foot and Ankle Surgeons Podiatric Medicine and Surgery Clinical Research Fellow at the Penn Presbyterian Medical Center in Philadelphia, Pennsylvania. After graduating podiatric medical school in 2016, Dr. Johnson went on to complete a three-year Podiatric Medicine & Surgery Residency (PMSR+RRA) at Aventura Hospital and Medical Center in Aventura, FL. Dr. Johnson is currently a PRESENT Podiatric Residency Education Summit Faculty Member. His research emphasis has been focused on gerontology, tropical and international medicine, regenerative medicine, diabetic limb salvage techniques, and rare dermatological and bone pathologies.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.