Skin care and cellulitis

QCellulitis is common in patients with lymphedema and usually is caused by bacteria called streptococcus. Why does the lower leg lymphedema seem more susceptible to cellulitis than the upper limb?

AThe entry point for bacteria to enter the skin is often between the toes because we don’t look after them as well as the hands. The favourable environment is a leaking capillary bed due to an epidermis in repair mode and a dermis overloaded by a failing venous response to gravitational factors on the veins of the leg. This is less of a factor in the arms. The result is an overloaded initial lymphatic system plus the effect of streptococcal elastases on elastin support of the initial lymphatics.

QBy Terence J. Ryan

immunity is impaired. The streptococcus often thrives between the toes, if there are cracks and debris there.

QWhat is the recommended treatment of care?

QWhat is the reason for the re-occurrence of cellulitis for many lymphedema patients?

ACellulitis is much more common in persons with lymphedema, as resistance/

ATreatment has several components: 1. Diligent skin care between the toes or any other crevasses. 2. Care of the epidermis of the leg so it does not need to be in repair mode. 3. Support stockings or elevation to reduce gravitational effects on the veins. 4. Skin movement (MLD massage, leg movement, Yoga) to encourage lymphatic function.

Is dry brushing a recommended strategy for skin care?

ADry skin may have loose cells on the surface; therefore, a soft brush or shower can help clean this up. Anything more vigorous will stimulate a repair mode and, in some persons, a triple response of redness and whealing (a raised wedge or welt on the flesh).

Compression while flying

QI have had breast cancer treatment and have no lymphedema issues but it has been suggested that I wear a compression sleeve when flying. Is this the right thing to do? Are there any reasons not to wear a compression sleeve in this circumstance? My sleeve has been properly fitted.

AThere is little research on the subject, but what evidence exists has led to relaxation of guidelines for arm lymphedema risk reduction. Modern aircraft are adequately pressurized, so there is little risk, especially for short-haul flights of 4-5 hours. Enjoy your trip! However, all adults should wear well-fitted compression stockings to prevent deep venous

QWhy do many clinicians seem to find it difficult to differentiate between cellulitis and other inflammatory manifestations related to chronic edema?

ADepending on the site of swelling and pain, in the early stages of infection, it may be challenging to distinguish cellulitis from recent trauma, such as sprains or deep vein thrombosis. However, full-blown cellulitis is easy to recognize. Symptoms like fever and a raised white blood cell count accompany full-blown cellulitis. LP

You can read more about the work of Professor Ryan in the Winter 2022/2023 issue of Pathways and in recent published articles in Journal of Lymphedema and British Journal of Dermatology.

Editor’s Note:

Studies showed the risk for cellulitis was reduced by 77% if wearing compression stockings. See Pathways Spring 2021 “Compression counters cellulitis” by E. Webb.

By Anna Towers

thrombosis (DVT) in the legs during longer haul air travel, and also should do gentle exercise during the flight. Well-fitted means that you should buy the stockings from a specialized fitter. This may mean that the garments are flat-knit and custom-made. Going back to lymphedema risk reduction, if you are a breast cancer survivor who has had a sentinel node biopsy and are of normal weight, you should

not worry. If you are at a higher risk to develop upper limb lymphedema following breast cancer treatment (due to obesity, axillary node dissection, previous cellulitis in the at-risk limb), and you choose to wear a sleeve and glove for long-haul overseas flights, again—they should be well fitted. You don’t want a tourniquet on your arm that will trigger lymphedema!

Anna Towers, MD is Director of the Lymphedema Program at the McGill University Health Centre (Montreal, Canada), is a Founding Member of the Canadian Lymphedema Framework and sits on the Editorial Board of Pathways

Terence J. Ryan, DM, FRCP is Emeritus Professor of Dermatology at Oxford University in Oxfordshire, England and a long-time mentor for the Lymphoedema Programme at the Institute of Applied Dermatology in Kerala, India. He has held senior posts and founding roles in numerous dermatology and wound healing organizations from which he has received many Lifetime Achievement Awards.