Research Advances
Compression counters cellulitis How compression therapy substantially reduces the recurrence of cellulitis By Elizabeth Webb
This following is a brief synopsis of the results of the randomised controlled trial ‘Compression Therapy to Prevent Recurrent Cellulitis of the Leg’. The full report can be accessed through the New England Journal of Medicine. www.nejm.org/doi/full/10.1056/NEJMoa1917197 What is cellulitis? Cellulitis is a common bacterial infection of the skin and tissue beneath the skin. It presents as a red spreading rash that can be hot, painful, and/or swollen. It can occur anywhere on the body but most often occurs in legs. For some people it can make them very sick, requiring hospital admission. Although many people have never heard of cellulitis, in the United States it leads to over 650,000 hospital admissions per year and it is estimated there are 14.5 million cases annually.1 Those with chronic edema (edema lasting three or more months) are at greater risk of developing cellulitis. A recent study by Burian et al. showed that in patients with chronic edema, 16% were diagnosed with cellulitis within the last year, and 37% had suffered an episode during their lifetime.2 Cellulitis reoccurs One of the challenges with cellulitis is that it is likely to reoccur. Up to 47% of those who have experienced an episode of cellulitis will have a repeat infection within three years3 with some people suffering multiple infections. This can cause significant personal challenges, impeding people’s ability to work and function. Similarly, it can contribute to substantial social challenges, causing extended periods of sick leave and often contributing significant
costs to the healthcare system, including the risks and demands of antibiotics in a climate of increasing antibiotic resistance. Cellulitis/edema – a vicious cycle Unfortunately people with chronic edema/ lymphedema are already at an increased risk of developing cellulitis. Sadly, when an episode of cellulitis does occur, it damages the lymphatic vessels further, leading to worsening swelling and even greater risk of repeated cellulitis infections, making it a vicious cycle.
Elizabeth Webb, PT is a physiotherapist working in the lymphedema service at Calvary Public Hospital Bruce in Canberra, Australia. She is currently completing a PhD through the University of Canberra investigating the impact and cost of compression therapy on recurrent cellulitis.
Spring 2021
Preventing cellulitis Previously the only known effective treatment to prevent cellulitis was antibiotics. Prophylactic antibiotics are effective in preventing cellulitis, but only when they are being taken, with the effect diminishing once stopped. For many years, clinicians and experts in the field of lymphedema have believed that managing chronic edema with compression would decrease the risk of cellulitis infections, but until recently, there has not been sufficient evidence to support this theory. New research The Calvary Public Hospital Bruce lymphedema service in Australia, started a randomized controlled trial to explore whether managing chronic edema with compression therapy would Ly m p h e d e m a p a t h w a y s . c a 5
prevent cellulitis from reoccurring in the legs.4 Participants with chronic leg edema who had a history of two or more episodes of cellulitis were eligible to participate. All participants were educated on the importance of good skin care (regular moisturizing and preventing cuts, scratches, bites and fungal infections between toes), healthy weight management and regular exercise. However, only approximately half of the participants were given compression therapy (compression garments with or without a short period of compression bandaging). We then monitored the compression and the control groups for recurrent episodes of cellulitis, cellulitis-related hospital admissions and leg volume every six months.
Research findings Eighty-four participants were enrolled in the trial. Many had multiple factors contributing to their edema, with the most common factors including obesity, venous disease, trauma or surgery. The average age was 64 and most patients suffered from obesity (with an average Body Mass Index of 41). Forty-one patients were randomly selected to be provided with compression therapy. Of these, 59% required a short period (usually between 3-5 days) of compression bandaging to reduce their edema prior to measuring for and fitting of compression garments. Almost all garments provided were knee high, with over half being custom-made due to patients’
COMPRESSION THERAPY HAS GLOBAL IMPACT A WORLD-FIRST RANDOMISED TRIAL
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CHRONIC OEDEMA IS A BIG PROBLEM
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Chronic oedema of the leg is a risk factor for cellulitis. Cellulitis contributes to about 130,000 hospital presentations per year, resulting in approximately 70,000 hospital admissions per year.
CAN CELLULITIS BE PREVENTED? Cellulitis is associated with high health costs and adverse health outcomes. Researchers set out to test whether compression therapy could prevent recurrent cellulitis of the leg.
3 WORLD-FIRST TRIAL
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Patients with chronic oedema of the leg and recurrent cellulitis participated in this world-first, single-centre, nonblinded trial. Skilled lymphoedema therapists applied compression therapy on 41 of 84 patients with oedema of the leg and recurrent cellulitis.
THE RESULTS ARE EXCITING Compression therapy resulted in a: • 77% reduction in risk of cellulitis • 50% reduction in hospitalisations showing it to be an effective non-pharmaceutical intervention.
5 IT’S A WRAP Compression therapy resulted in a lower incidence of recurrence of cellulitis than conservative treatment. Proudly brought to you by:
CHECK OUT THE RESEARCH PAPER AT TINYURL.COM/Y5DL7F8B
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Compression bandaging. legs being outside the ready-made garment standard size range. Approximately 75% of the garments prescribed were flat-knit. Participants were asked to wear their compression garments daily and garments were usually replaced every 6-12 months. Of those assigned to compression therapy, almost 90% reported wearing their garments 4 or more days per week. Halfway through the trial, a planned interim analysis identified a clear difference between the two groups, demonstrating that compression therapy did substantially reduce the recurrence of cellulitis. The study was reviewed by an independent committee who believed that continuing the trial would be unethical and therefore recommended that the trial be stopped early and that every patient be provided compression therapy. Cellulitis reoccurred in 40% (17/43) of those without compression garments (the control group), and only 15% (6/41) of those with them. Not only were there fewer episodes of cellulitis in the compression group but they also tended to occur later compared to the control group. This demonstrated that compression therapy reduced the risk of cellulitis reoccurring by a staggering 77% in those who received treatment. Further, compression therapy contributed to a significantly reduced leg volume by an average of 362ml over 18 months. This is a substantial change in leg volume considering it was only measured in a small portion of the leg between the ankle and the knee. During the trial 14% (6/43) of the control group were hospitalized for cellulitis, compared to only 7% (3/41) of those in the compression group. Spring 2021
Compression garments.
obesity, or who have had multiple episodes of cellulitis (>3).5 As all the patients in this study had one or more of these risk factors, it is very exciting to discover compression therapy is an effective treatment in those at risk of failure with prophylactic antibiotics. How does compression therapy prevent cellulitis? The relationship between cellulitis and edema seems to be multifactorial. If the lymphatic system is impaired this not only causes chronic edema but may also impair the body’s immune response to pathogens. Further,
Whilst this result was consistent with the primary outcome of cellulitis recurrence, it was not statistically significant which was likely related to the small number of study participants. Before this trial, antibiotics were the only known prophylactic treatment for cellulitis. However current research suggests that they are less effective for those who suffer from edema,
chronic edema can damage skin integrity allowing for opportunistic bacteria to breach the skin barrier and can provide a rich medium in which bacteria can flourish. By improving lymphatic drainage, compression therapy may therefore prevent cellulitis by reducing edema volume and thus the medium for bacterial growth, improving skin integrity to stop bacteria breaching the skin and/or improving the body’s immune response to pathogens. LP A full set of references, including the results of the trial can be found at www.lymphedemapathways.ca
Key points 4 Compression therapy reduced the risk of cellulitis by 77% in patients with chronic edema and a history of two or more episodes of cellulitis. 4 Compression therapy reduced the risk of cellulitis in a cohort of patients for whom prophylactic antibiotics are less effective (i.e. patients with edema, obesity and/or a history of three of more episodes of cellulitis). 4 The clinical implications are that compression therapy should become standard practice for people with chronic edema experiencing cellulitis. 4 Preventing cellulitis may reduce the use of antibiotics, which is important in our current climate of increasing antibiotic resistance.
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