The differential diagnosis of lymphoedema from other chronic oedema and mixed oedema is based largely on a good history, but there are some investigations that would help differentiate and therefore direct patient care more appropriately.
Quick flowchart of Lymphoedema differential diagnosis and a Cellulitis or Red Legs Flowchart
An article has been published in BMJ on open access – What diagnostic strategies can help differentiate cellulitis from other causes of red legs in primary care? Edwards et al Feb 2020
Risk factors for lymphoedema – cancer and it’s treatment particularly if it includes surgery or radiotherapy likely to affect the lymphatic system (or nodes) e.g. breast cancer with axillary clearance, gynaecological cancer or melanoma surgery which includes inguinal node clearance. For non-cancer patients – physical trauma to lymphatics; hereditary pattern; long-standing poorly controlled chronic venous oedema. Obesity is a risk factor to both categories. This should be differentiated from the separate condition of Lipoedema.
Early warning signs of lymphoedema – many patients initially experience a dull ache, tightness or ‘strange sensation’ in their limb before swelling is measurable by circumference. In research, bioimpedence tests show an altered physiological state. This may then be followed by a period of transitory, reversible swelling. At this early stage lymphoedema is at it’s most manageable and self-management advice would have most effect. Referral to a specialist service for education/advice should be considered.
Use of diuretics – Diuretics (water tablets) are generally not recommended for lymphoedema. However, they may be used in some circumstances where there may be more than one cause for the swelling (e.g. heart/renal problems) or palliative care. Patients are advised not to stop taking prescribed medication without first discussing it with their General Practitioner. The Lymphoedema Support Network (patient support and information charity) produces a fact sheet on the use of diuretics in lymphoedema which is free to its members.
Holiday and travel advice – for travelling abroad provision of antibiotics for lymphoedema patients may be considered.
Taking blood/injections/removing skin lesions on a lymphoedematous area – robust evidence remains lacking as to the effect of these procedures on the lymphoedematous limb however due to the sheer number of anecdotal patient histories of the condition being triggered or worsening in response it is generally considered good practice to avoid the swollen limb if possible e.g. using the opposite arm and the LSN produce wrist bands for patients to empower them to discuss this with their health professionals. Lymphoedema Specialists will advise patients however that it is an issue of ‘relative risk’ and that the procedure they are requiring may not be possible in another limb and may be relatively more important for their immediate health.
Lipoedema occurs when there is an abnormal accumulation of fat cells within the tissues of the skin. This results in swelling mainly in the legs, but the feet are spared. It almost always affects women and it can be hereditary. Lipoedema can be painful and it is also a chronic condition. There are now Guidelines for the Management of Lipoedema available from http://www.wounds-uk.com/pdf/content_11939.pdf For more information, visit Lipoedema UK