Infection and overlying skin changes in lymphedema A research review on lymphedema related infections
Why lymphedemic limbs are prone to infection and tips on proper skincare
By Arissa Jean Sperou (primary author) and Laurie Michelle ParsonsAnatomy of the skin
The epidermis is the most superficial layer of the skin. It is comprised of epithelial cells that synthesize a protein called keratin, which protects the surface of the skin. The dermis is the layer in the skin that lies deep to the epidermis and is comprised mainly of collagen and elastin. Beneath the dermis lies the subcutaneous tissue, which is comprised primarily of adipose tissue, commonly known as fat cells.
The lymphatic vessels travel with blood vessels, reabsorbing excess fluid that leaks from the capillaries, and returning the filtrate to the circulation. These blood vessels and lymphatics originate deep within the subcutaneous layer but branch to pass through the super ficial subcutaneous tissue and dermis. Impaired reabsorption causes protein-rich lymph to pool within the subcutaneous tissue of lymphedematous limbs. Accumulation of lymph within the interstitial spaces can distort normal skin architecture and function.
Cellulitis and other infections
The lymphatic system plays a role in adaptive immunity, and helps to prime the body to
respond to infection. Typically, the lymphatic system shuttles immune cells (macrophages, lymphocytes) to lymph nodes, where the body recognizes invading pathogens and mounts an immune response in defense. Abnormal lymphatic drainage can dampen these processes and can hinder the body’s ability to recognize and attack foreign pathogens. Patients with lymphedema are more disposed to developing recurrent infections within the affected limb, likely due to altered immune surveillance.
Cellulitis refers to an infection of the skin or subcutaneous tissue and is characterized by redness, swelling, warmth, and pain. Symptoms such as fever, chills, rigors, headaches, and vomiting, might indicate greater severity. Cellulitis is often caused by streptococcus or staphylococcus bacterial infection. Depending on severity, cellulitis can be treated with antibiotics, either at home or in the hospital. Some patients with a history of recurrent cellulitis could need prophylactic antibiotic therapy to prevent reoccurrence. In one case-control study, it was reported that patients who were admitted to hospital with
3d rendered close up of isolated staphylococcus bacteria.
thus suggesting that lymphedema is a significant risk factor for developing cellulitis. Another study followed a cohort of patients with lymphedema over a 12-month period and found that 29% (64/218) developed cellulitis in that year. Although patients are at a greater risk of developing skin infections in the lymphedematous limb, it is thought that generalized systemic immunity is not compromised in most patients. Cellulitis itself may predispose vulnerable patients to developing lymphedema. There is some evidence to suggest that patients who present with sub-clinical lymphedema and cellulitis are at a greater risk of developing overt lymphedema post-infection.
Arissa Sperou is a second year medical student at the University of Calgary and is the primary author of this article. In her future practice, she hopes to provide care to patients with lymphedema. Dr. Laurie Michelle Parsons is a Calgar y dermatologist. She reviewed this article prior to submission.
Fungal infections can also develop between the toes or on the nails of patients with lymphedema. A diagnosis can be made by analysis (mycology) of skin scrapings or nail clippings taken from the patient. An
anti-fungal preparation can be used to treat the infection. Folliculitis, characterized by pustules where the hair shaft pierces through the surface of the skin, is another infection that patients with lymphedema can develop. This is an infection of the skin’s hair follicle. Folliculitis can develop as a complication of emollient therapy. One must remember to care for these infections, as they can dispose patients to developing cellulitis.
Overlying skin changes
Lymphedema is associated with a spectrum of skin changes such as fibrosis, enhanced skin folds, hyperkeratosis, dermatitis, papil lomatosis, and lymphorrhea to name a few skin-related complications. With the progres sion of skin-related changes, the clinical stage of a patient’s lymphedema also progresses.
Fibrosis
Stagnation of protein-rich lymphatic fluid contributes to inflammation within the affected tissue interstitium. Inflammation contributes to increased fibrin and collagen deposition, which causes fibrotic hardening of the skin and connective tissue. Swelling and fibrosis can contribute to the development of skin folds in enlarged lymphadematous limbs. These skin folds can foster fungal and/or bacterial infection, increasing the risk of developing cellulitis.
Hyperkeratosis
therapy and/or topical anti-inflammatory preparations (such as topical corticosteroids).
Papillomatosis
This skin change is characterized by outgrowths and protrusions of lymphatics in the dermis. Over time, papillomatosis can cause the skin to develop a cobble-stone appearance and to look “warty.” This skin change is often the result of chronically inadequate treatment.
Apply emollients (creams or ointments) to the skin to keep it well hydrated in order to prevent it cracking and bleeding. Ointment formulations are often better moisturizers than creams but can be greasy. There is no consensus regarding which direction to apply emollients. However, applying the emollient in gentle strokes towards the trunk can improve lymphatic flow, and finishing off the application with one downwards stroke (in the direction of hair growth) is thought to reduce the risk for development of folliculitis.
Hyperkeratosis is characterized by the excess proliferation of keratin overlying the epidermis. Keratin is a protein produced by epithelial cells, and its proliferation causes the skin to look brown and scaly. This skin change occurs early in disease development, and is thus commonly noted in patients.
Dermatitis
Contact dermatitis is characterized by an inflammatory reaction within the skin that produces a rash. Irritant dermatitis is usually characterized by a well-demarcated rash limited to the area of contact with the irritant. Allergic dermatitis is usually characterized by a more widespread rash, which might extend beyond the area of contact with the allergen. In cases where dermatitis develops, it is important for patients to seek treatment from their healthcare provider, who might suggest emollient
Skin care is one of the four cornerstones of complete decongestive therapy, as it decreases the risk of infection and overlying skin changes.
Lymphorrhea
Excessive pressure buildup, caused by underlying edema, can cause beads of lymph fluid to leak out from the skin. Over time, this can lead to softening of the skin and sometimes breakdown of the skin called maceration. The miniscule openings in the surface of the skin can act as entry points for pathogens such as bacteria, and can dispose patients to developing cellulitis.
Skin care and wound management
Skin care is one of the four cornerstones of complete decongestive therapy. Maintaining healthy skin is of paramount importance, as it decreases the risk of infection and overlying skin changes.
It is important to clean the skin over the affected limb daily, paying particular attention to cleaning between skin folds and around nail beds. The best cleanser to use is a pH balanced soap product without detergents or scents. Regular soaps often contain detergents and therefore these should be avoided because they can dry the skin. Scented soaps should also be avoided as these could cause an allergic reaction or contact dermatitis for some patients. After washing, patients should take care to thoroughly dry the skin.
It is prudent to avoid activities that could lead to cuts and scrapes, and to take appropriate precautions to avoid injuring oneself during outdoor or vigorous activity. As an example, wearing good shoes, gloves, and protective clothing can be effective in preventing minor injuries. Using an antibacterial ointment or cream for minor cuts or scratches can also minimize risk of infection from injury. If signs of cellulitis start to develop (pain, redness, warmth, or swelling), it is important for patients to seek medical attention immediately. It is important for patients to cut their nails straight across and not to cut their cuticles, as this could introduce bacteria or fungus into the underlying tissue. Patients should avoid getting manicures or pedicures in the affected limb, as these procedures could carry the risk of introducing pathogens into the underlying skin, which could dispose a patient to cellulitis. If an ingrown toenail occurs, the patient should make an appointment to see a nail care professional such as a podiatrist, chiropodist or foot care nurse who has an understanding of lymphedema care.
Conclusions
Lymphedema is a chronic condition that requires lifelong management to avoid complications. Complete decongestive therapy (CDT) refers to treatment combining manual lymph drainage, compression bandaging, remedial exercises, and skin and nail care. CDT is effective in preventing overlying skin changes and infection in patients with lymphedema. When infection and skin changes do occur, it is important for patients to seek the care of a general practitioner or a dermatologist to manage skincare needs. LP
Find references at lymphedemapathways.ca