Lymphedema: Skin and Wound Care in an Aging Population

Author(s): 
Michael J. King, MD, FACC, FACP; and Elisa G. DiFalco, CLT-LANA

L ymphedema is a complex, unappreciated, and chronically progressive medical condition. Appropriate management requires a correct diagnosis and an understanding of the underlying pathophysiology. Fluid retaining conditions and mechanical problems both can lead to edema. Diuretic therapy may be correct for certain patients but can be harmful to others. Although lymphedema is not curable, it can be controlled and managed.1,2 Multiple medical and surgical subspecialties are usually involved in treatment.

Lymphedema is an increasing medical problem in this country. This is partly the result of medical personnel having little or no training or understanding of the condition. Consequently, patients are frequently left untreated or treated incorrectly. Increasing longevity leads to complications that are part of the natural history of lymphedema and aging. These complications never had time to develop to a point of clinical significance in the past. However, now they are seen in greater numbers. Likewise, dermatological problems increase with age. Edema in elderly patients with loss of elasticity, collagen, and vascular supply now result in problems, the frequency of which has not been seen in the past.

Most lymphedema in this country is the result of surgical treatment for a malignant disease. Because malignancy is increasingly curable, the latent potential for developing lymphedema is a growing medical problem.

Skin care always has been an important part of lymphedema treatment. With the skin changes of aging, even basic skin care and standard treatments such as manual lymph drainage, compression wrapping, and the use of stockings and sleeves are becoming difficult or impossible in patients with certain dermatological/medical disorders. Further complicating matters is the fact that skin ulcerations can have multiple causes. What is clear, however, is that skin lesions and ulcerations, regardless of origin, are difficult or impossible to heal in an edematus extremity. Yet therapy to relieve edema in the presence of wounds may not be possible, creating a "catch 22."

The lymphatic and venous systems are closely related and interact with each other. Problems in one area will inevitably lead to problems in the other. Both lead to a final common pathway. The target organ is the skin. Often, the result is the need for wound care, but hopefully advancement to this stage can be prevented.

The Lymphatic System

Lymphatic "circulation" is a misnomer. Normal circulation involves arteries and veins with the heart the driving force. In true circulation, the arteries deliver nutrients and oxygen to the tissues and capillaries on the venous side return blood back to the heart and lungs to be replenished. Without going into membrane physiology and physics at any length, fluid constantly shifts in and out of the standard circulation to interstitial spaces outside the vascular system. This is the result of physical laws involving pressure gradients, colloidal osmotic pressure, and a concept called ultrafiltration. To oversimplify things, Nature likes to equalize things across a barrier. Approximately 10% of the normal circulatory fluid filters into the interstitial spaces. Our bodies are endowed with additional vessels known as lymphatics. These vessels begin in the tissues. They act like garbage pails, picking up large protein molecules and other materials which, because of their size, are unable to filter back into the normal venous circulation. This is actually a half "circulation" that lies in close conjunction with the venous system; it is quite intricate and complex. The fluid movement in the lymphatic system is not dependent on the pumping of the heart. The smaller lymphatics lead to larger ones that have smooth muscle and neurological connections.

References: 

1. King MJ. Lymphedema - the role of the physician. Contact the author.
2. King MJ, DeFalco E. Multiple radio tapes and articles. Contact the author.
3. Foldi M, Foldi E, Clodius. The lymphedema chaos. Ann Plast Surg. 1989;22:505.
4. Tehrani H. International Varicose Vein Congress. Miami Vein Center. Key Biscayne, Fla. September 21, 2003.
5. Hartmann M. CVI. In: Weissleder, Schuchardt. Lymphedema - Diagnosis and Therapy. Viavital Verlag GmbH; 2001:266-282
6. Cass LA, De Poli P. Manual Lymphatic Drainage Therapy: An Integral Component of Post-Operative Care in Plastic Surgery Patients. Abstract lecture. Northwestern University of Medical School.



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