Clinical Perspective
Living well with lymphedema: skin care secrets
Based on clinical experience By Robyn A. Smith This article is based on a presentation given at the National Lymphedema Network 2017 annual conference Patient Summit held Oct 18-22.
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kin! Anatomy class tells us it’s the largest functioning optimally? The skin changes organ in our body. It alerts us when the that come with lymphedema add additional pan on the stove is too hot to hold, it allows challenges to keeping skin doing its assigned us to feel the softness of a baby’s cheek or job. One of the four facets of Complete the pat on the back for a job well done. When Decongestive Therapy (CDT) is skin hygiene; I was a child, I used to think our skin was a so let’s look at several ways you can keep solid, plastic-like wrapping that kept all of our your skin in top form. insides in place and if it got a puncture in it, such as with a vaccine injection, that all of Read the labels “me” would “leak” out. But when I became First and foremost, we need to become a teenager interested in anatomy experts at reading product labels. studies and later a health care Fragrance in products is a no-no. practitioner, I learned my Are you aware that a product childhood understanding can proudly list UNSCENTED couldn’t have been farther on the front label of the from the truth. Skin turns out product whilst still adding to be a stack of cells that are fragrance? Two different better described as a brick wall categories of product fragrance with a flexible mortar of lipids exist, each being treated Brick-like pattern of the skin differently in declaring that allow for a transference Mortar: Lipids of elements in/out of the a product unscented. Bricks: Skin cells body. That brick wall is Fragrance added for the further covered in a naturally occurring, protective acid barrier that stymies most bacteria before they even have a chance to invade the insides of our body. It is a fortress that miraculously heals a breach in the wall when required and even thickens up that wall when more protection is needed. Amazing! However, what if that skin is not
express purpose of making it smell pretty is called “scent”. Fragrance added to mask the medicinal smell of some ingredients is called “masking fragrance” and can be added and still considered unscented. Think of the front label of a product as the marketing label, the one designed to make you want to buy the product. It’s the back list of ingredients that
Robyn “Redd” Smith, MEd, COTA/L, CLWT, CLT is an Occupational Therapy Practitioner, Certified Lymphedema & Wound Therapist (CLWT) and owner of Life Rehabilitation, a private lymphedema practice located in Salt Lake City, Utah, and is also the Clinical Education Liaison for SIGVARIS, INC.
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CAUTION Given that there is little evidence-based literature regarding many of these practices, the majority of the recommendations/tips must at this time be based on the knowledge of pathophysiology and decades of clinical experience by experts in the field. As with any other suggestion, use your judgment and if in doubt, consult a health care professional.
we really care about, as it is required by law to be factual and non-misleading. Also important is the ingredient’s placement in the ingredient list as they are listed in the order of percentage in the product. Key point to remember? Carefully read ingredient labels on the back before using any product. Keep it clean (but not too clean) Keeping your skin free of the microorganisms that can cause infection is an important part of skin care. However, over-cleansing can also do damage. The skin’s acid barrier is the first defense our bodies have against the germs that surround us; most bacteria cannot survive for long in a high-acid environment. Over-cleansing can wash away that natural protective barrier and allow bacteria to sneak in between the “bricks” of our skin cells. There are several low pH, non-allergenic products available that allow the acid barrier to safely remain in place. Talk to your pharmacist or dermatologist for specific recommendations. Balancing moisture—don’t sweat it! Picture that brick wall again. The skin cells are held in place by a mortar of epidermal Spring 2018
Brick and mortar-like structure of normal skin. lipids. Lipids are the naturally occurring fats/oils that provide a barrier against the inadvertent movement of water and electrolytes out of the skin as well as a barrier against microorganism invasion into the skin. Dry skin allows in pathogens that love nothing more than overwhelming your immune/ lymphatic system; keeping invaders out is paramount! Keeping your skin moisturized is your way of fighting back. Whether your personal preference for moisturizers is using thick creams or ointments, both work equally well. Apply moisturizing products anytime your skin feels dry or visually appears to be dry. If it looks dry, it is dry. However, sometimes dry skin is not the trouble. Skin can also be too moist. Skin folds common to lymphedema often lead to overly moist areas caused by perspiration. This moisture can lead to a condition called intertriginous dermatitis (ID) or intertrigo, an inflammatory condition of skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation. Unfortunately, if that moisture is left without care, it When cleansing a few rules apply: 1 Always wash top to bottom (to avoid irritating hair follicles and developing folliculitis) 2 No extreme hot water on areas with lymphedema (hot water = more blood to area = more fluid to leak into tissues) 3 Wash gently – do not use loofahs or other exfoliating means which will cause further damage of the skin “bricks” and breaking down of the acid barrier.
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will progress from an area of redness, to rash, skin breakdown, then unhappily ending in an open wound. Further, this unwanted moisture in the skin folds forms a perfect breeding ground for infections, both bacterial and fungal. There are two ways to deal with this excess moisture; control the moisture and/or protect the skin from direct contact with the moisture. There are products available with moisture wicking fabrics that also contain antimicrobial silver. A single layer of cut-to-size fabric is
Dry skin allows pathogens to enter the body between the skin cells. tucked into the skin fold with a small portion of the fabric remaining outside the fold. The fabric then wicks the moisture from inside the fold to outside the fold, which then evaporates. Antimicrobial silver keeps the microbes from attacking and keeps the odor at bay. Sometimes there is just no way to keep moisture at bay, whether from perspiration, urine or lymphorrhea. Using a skin barrier cream can protect the skin from breakdown and allow the moisture to evaporate or be drawn into incontinence briefs or dressings. There are products available in the form of ointment or protective wipes. Functioning primarily as a barrier to moisture, specific ointments are quite calming to the skin decreasing itching due to dry skin. However, ointment form does not allow for use where a wound dressing or even a simple Band-Aid is needed. In that case, there are protective wipes available that are wiped on the skin around a wound and quickly dry into a protective layer. These ‘protective’ commercial wipes should be prescribed as they often contain sensitizers such as MCI. One reminder about scratching. If you absolutely cannot leave that itchy skin alone, use the pat or push method to stop that itch.
Gently pat the area or firmly push on it. Never use your fingernails to scratch. To heal or not to heal Whether we call it weeping, wetness or by its proper term of lymphorrhea, that leaking of yellow-tinged fluid onto the skin is something that must not be ignored. One of our lymphatic system’s main jobs is to break down dead cells so they can be returned to the blood stream and be excreted out of the body via the kidneys. Wait! Isn’t skin made up of proteins? What happens when lymph fluid leaks out and becomes lymphorrhea (translated as “lymph flowthrough”) ending up on the skin? It continues its job of breaking down protein on your healthy skin. What starts as a tiny drop of fluid can progress from a tiny red spot on the skin to an open wound only days later. Lymphorrhea’s caustic properties make caring for it of critical concern. Lymphorrhea needs to be removed from the skin quickly and additional leakage controlled properly. What happens if lymphorrhea leaks have started in several places on the limb? The proper protocol is to place an absorbent dressing on each wound to keep the fluid from pooling on the skin and then, add enough compression to counter the pressure that is causing the leakage. If the area has progressed to a larger area of skin breakdown
Lymphorrhea. requiring more than just a spot dressing, keep the dressings just the size necessary to cover the wound. Use skin prep wipes around the actual wound margin and place the smallest dressing possible to protect the wound. Apply an absorbent pad that contains modern starch polymer technology (used in diapers and incontinence pads) so that the moisture is locked away. Problems can also be avoided by more frequent changes. If several areas of wound dressings are necessary, the use of an underliner stocking will protect the dressings from being pulled off when donning/doffing L y m p h e d e m a p a t h w a y s . c a 13
Whether we call it weeping, wetness or by its proper term of lymphorrhea, that leaking of yellow-tinged fluid onto the skin is something that must not be ignored. the compression garment by allowing the compression to slide easily over the dressings. An ounce of prevention Sometimes the greatest amount of prevention can be enjoyed from the smallest of changes in our lifestyle. Some of the changes that will slow future progression and lessen the complications of skin breakdown, lymphorrhea flareups, or hospitalizations due to cellulitis can be made simply and immediately. •W ear insect repellent and high SPF sunblock whenever you are outdoors. A simple mosquito bite or a sunburn can sometimes be the catalyst for a huge increase in swelling.
•W ear protection on your hands and/ or feet whenever there is a chance of damage; gloves when working in the garden, washing dishes, or washing the car; shoes anytime walking outdoors and preferable indoors as well. Keep hands and feet from extremes of temperatures whenever possible. Many times, there is a loss of sensitivity in lymphedematous skin that can lead to injury due to the loss of warning feedback from your skin. •W ear compression at the prescribed level/ dosage and duration requested (daily/ day and night). Most people diagnosed with lymphedema are advised to be in compression garments, whenever out of bed and preferably 24/7 for improved outcomes. Without compression, the other elements of your lymphedema therapy are destined to remain a rollercoaster ride of skin breakdown and wound eruptions that may take months to heal. There are so many options now available for those needing compression, that excuses for not wearing (too hot or otherwise uncomfortable
or unfashionable), are no longer valid. • T horoughly check your skin each night for new redness, lymphorrhea or other problems so you can address them immediately. Vigilance allows you to catch a small problem and stop it from it becoming an emergency. • T reat funcal infection of the feet quickly. •M easure your limbs weekly or monthly as directed by your physician or lymphedema therapist and keep a chart of your progress. If a negative change is seen you can be confident you have caught it early and you can involve your lymphedema therapist or physician in developing a plan of care. Wrapping things up—a few final words That amazing fortress you call your skin is silently protecting you from the hordes of microorganisms that want to wreak havoc to your lymphatic system. With gentle care, proper products, small changes to your routine and an above average amount of vigilance, you can ensure that nothing bad gets in and nothing good leaks out. LP
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