The British Medical Journal (The BMJ) (2022) describe lymphoedema as:
‘a chronic, progressive swelling of tissue with protein-rich fluid, which is consequential to the developmental (primary lymphoedema) or acquired (secondary lymphoedema) disruption of the lymphatic system.’
Usually, the peripheral areas are affected first, such as the hands, ankles and feet, followed by regions such as the genitalia. Usually, these cases are a result of nematode infection known as filariasis, malignancy, or caused by cancer-related treatments. Ususally, such a presentation involves a painless unilateral limb swelling with pitting oedema present in early disease (The BMJ, 2022). Lymphoedema is usually diagnosed via a clinical assessment involving the confirmation of disease by lymphoscintigraphy (The BMJ, 2022). The initial treatment will involve compression, using certain types of static garment such as compression hosiery, and sometimes involves complex massage and pneumatic compression devices, with surgical options reserved for those patients with significant morbidity who did not respond well to conservative measures (The BMJ, 2022). A permanent cure is not available and long-term care will be required, with collaboration between the patient and their care providers.
Lymphoedema and chronic oedema are common throughout community caseloads. Skincare is an integral part of the treatment to ensure infection prevention, in the management of fluid excretions, to assist patients with pain management. Skin integrity must be maintained to avoid any breakdown of the skin. Community nurses (CNs) have a significant role in skincare and this article will provide an overview of chronic oedema or lymphoedema care requirements.
Lymphoedema Scotland (2020) state that skincare is crucial in reducing the risk of cellulitis and to keep the skin soft and supple so as to avoid breaks. The skin must be prevented from becoming dry and cracked, using daily skincare, observation, cleansing and moisturising, with a routine in place being adjusted to the patient's individual needs. When considering skincare regimens, the advice for lymphoedema is very similar to that provided for chronic oedema.
Marie Curie (2021) advise on the importance of avoiding any cuts or scratches, as these can provide entry to bacteria that may cause cellulitis, which would then mostly require treatment with antibiotics. This type of skin tissue infection can cause long-term issues with skin integrity; therefore, despite it being somewhat treatable, it is crucial that it is avoided by maintaining clean skin and keeping to the daily skincare regimen that has been decided before hand. Signs of cellulitis include redness, warm/hot skin temperature, increasing swelling, and pain around the affected area. Observations are therefore important for monitoring and preventing infection. Where cellulitis is suspected, it is essential that the patient has timely access to antibiotics. Therefore, the patient should contact the general practitioner (GP), or case manager/independent nurse prescriber or the assigned district nurse (DN) to organise this.
The care plan must clearly define the care regimen for the patient's skin, including diagrams and measurements of the legs and other affected areas, so that fluid buildup is monitored in accordance with the level of bandaging that may be in place, along with any wounds in the area, alongside detailing individual dressing requirements for the wounds. A specialist wound care nurse can assess the patient and detail what care is best. Such care would involve regularly washing the skin with gentle soap and water, drying the skin thoroughly after to prevent skin breakdown, daily moisturising with emollients, and management to prevent leakage of fluid, known as lymphorrhoea (Marie Curie, 2021). Cannulation, blood pressure monitoring and venepuncture should be avoided on the affected arm or leg as these can also cause skin breaks, potentially leading to cellulitis.
A complication of either lymphoedema or chronic oedema is ascites, a fluid build-up in the abdomen. This can occur when fluid is not being drained from the tissues into the circulatory system properly, potentially due to this system failing, or for example, because of blockage caused by a tumour. It is also important to be aware of conditions that may cause ascites. Most commonly, conditions such as cancer, specifically ovarian cancer, heart failure, renal failure and liver failure may result in a patient being more at risk of ascites. Symptoms include: pain and discomfort in the abdomen; swelling around the abdomen; problems sitting upright; nausea and vomiting; loss of appetite; acid reflux; constipation; and breathlessness (Marie Curie, 2021).
Where ascites is suspected, a senior healthcare professional should be contacted as soon as possible so that the condition can be managed promptly, thereby increasing the effectiveness of the treatment. In such a condition, the DN may manage the wound alongside tissue viability nurses (TVNs), and an indwelling drain may be required to allow the fluid to be drained at the patient's home by the nurses. When caring for the patient with suspected ascites, it is important to find the most comfortable positions for them to sit or lie in, prevent pressure sores by providing good skincare, support mobility, advise on short periods of exercise with a lot of rest in between, manage pain, report sudden swelling with urgency, monitor for signs of infection, and monitor the patient for signs of breathlessness, as fluid buildup may cause abdominal pressure against the lungs (Marie Curie, 2021).
Particular skin problems that are commonly associated with cases of chronic oedema or lymphoedema include dermatitis and eczema, characterised by red itchy and weeping skin. Scratching can worsen the lymphoedema and skin integrity, which in turn, causes skin breaks that are then difficult to heal and prone to infection (Marie Curie, 2021). The eczema may be caused by allergens and can be avoided by use of unscented emollients, which reduce the risk of allergic reactions. Fungal infections are also common in oedematous skin and where untreated, this can cause cellulitis. Fungal infections between toes are important to flag up to the patient's GP and skin specialists, so that the correct anti-fungal treatment can be prescribed. Lymphorrhoea can occur if the limb swells suddenly. Such sudden swelling can lead to skin breakage if the skin is not kept soft and supple, or where the skin becomes thin and fragile. The risk of infection increases where lymphorrhoea is present and therefore, the best treatment should be sought from a specialist when the nurse or other practitioner/carer detects it (Marie Curie, 2021).
In general, quite specific types of skin treatments are recommended, for lymphoedema patients, as described by Fife et al (2017). Topical agents containing lactic acid, urea, ceramides, glycerin, dimethicone, olive fruit oil or salicylic acid are recommended for hyperkeratotic skin desquamation. As salicylic acid is a keratolytic agent, it may improve the penetration of other topical agents through the skin. Salicylic acid ointment (6%), along with skin and nail care regimens are recommended for decreasing the risk of filariasis-related adenolymphangitis (ADL) attacks (Fife et al, 2017). Adenolymphangitis typically presents as painful lymphadenopathy and retrograde lymphangitis, normally affecting the inguinal nodes, genitalia and lower extremities, leading to extreme swelling, elephantiasis, secondary infection, and sometimes skin breakdown (Fife et al, 2017). Attacks often happen on a recurrent basis, lasting 4–7 days. The attacks can happen up to 4 times a year, depending on the severity of the lymphoedema.
Topical steroids may be needed for cases of chronic oedema and lymphoedema, which are also the mainstay of treatment for inflammatory dermatoses such as dermatitis. Patients with recurrent lymphangitis and systemic signs of infection may also require long-term, prophylactic, systemic antibiotics in order to reduce infectious episodes (Fife et al, 2017).
Daily good hygiene with careful washing is integral in reducing the chances of infection and its various causes in chronic oedematous patients. Soaps dry out the skin, and therefore, moisturising soap substitutes are better to recommend to a more independent patient, or for use by the nurse on their daily visit. Protection from sunburn, cuts, insect bites, injections, and hot water is required, as well as appropriate gloves or footwear to ensure skin breaks are avoided (Fife et al, 2017). If the patient wants to shave, it is recommended they use an electric razor, so that skin trauma can be avoided.
Non-perfumed emollients can aid the epidermis to retain water and can reduce water loss. Regular use of ceramide-containing emollients can assist in reestablishing the skin's protective lipid layer, helping to prevent water loss. These products are available as either lotions (oil and water preparations that usually have more water than oil and thus have a short-lived effect) or creams (oil-in-water or water-in-oil emulsions) (Fife et al, 2017). Creams are recommended as the first choice for dry skin. A word of caution however is to be aware that emollients may damage the elasticity of compression garments, therefore current recommendations include avoiding applying the emollient immediately before putting on hosiery.
Topical steroids, antifungals, and antimicrobials have been successfully used off-label for the conditions associated with lymphoedema, Fife et al (2017) comment. These preparations include tazarotene gel 0.1%. Tacrolimus in topical formulation has been suggested for off-label use as a possible alternative to topical steroids in the treatment of severe stasis dermatitis. Another aspect to consider as crucial is nail hygiene as a huge amount of bacteria can harbor under the nails, which may be made more possible in a disabled individual who is restricted in maintaining personal hygiene and in carrying out day-to-day personal care. In such cases, it may be useful to have a moisturising alcohol gel that is approved for use.
Overall, lymphoedema and chronic oedema are long-term conditions requiring collaborative care from the patient, CNs, GPs and other specialists. Infection prevention is crucial, alongside a high level of skincare individualised to the patient, aiming to maintain skin integrity, and with actions in place to avoid skin breaks, which are hard to heal once and can lead to complications. Monitoring the patient through observation, careful note-taking and reviewing the care plan in place are crucial parts of the patient's regular care so that the long-term oedematous skin can be managed, and complications such as cellulitis and eczema can be avoided and managed when they do occur. Use of preparations suitable to the patient is important and advice can be further obtained from the lymphoedema nurse or TVN.