Lymphedema is edema—swelling of tissues caused by fluid in the intracellular space—that is caused by dysfunction or disruption of the lymphatic system. The lymphatic system uses lymphatic vessels to absorb, transfer, and filter fluids from peripheral intracellular spaces and return these fluids to general circulation. When there is an obstruction or a structural change to the lymphatic system, typically experienced in response to surgical or neoplastic changes, the transfer of extracellular fluids from the periphery is inhibited, resulting in localized edema distal to the site of the structural deficiency.

Although lymphedema may cause discomfort, it can sometimes lead to more serious complications that will require additional management.¹ Most of the complications typically encountered with lymphedema are associated with the swelling that lymphedema can cause or with decreased immune surveillance because the lymphatic system no longer fully conveys its immunological benefits to the affected areas.

Wound Dehiscence and Delayed Wound Healing

Wound dehiscence or poor wound healing may result from lymphedema that is not well managed.² The additional pressure on the superficial capillaries may disrupt blood flow to the wound bed and delay healing. Additionally, in some rare cases, the additional pressure from the edematous tissues may cause dehiscence of existing wounds. Wound care for patients with injuries associated with lymphedema should include treatment of the lymphedema. This may be done through use of compression stockings, elevation of the affected extremity, exercise, or in some more severe cases, surgery.³ Diuretics should not be used alone to treat the lymphedema in the absence of cardiac issues because this would concentrate the proteins and other debris in the interstitial space, thus causing more fluid to accumulate.⁴ If dehiscence is experienced, the wound may have to heal by secondary or tertiary intention. Wounds with poor healing may benefit from negative pressure wound therapy. Wound care should initially be done under the supervision of a wound specialist until it is determined that the patient is able to provide the level of wound care needed.

Infection

Fungal infections or cellulitis may be experienced by patients with lymphedema.^1,5,6 The decreased immune surveillance secondary to lymphatic disruption is the primary factor responsible for this increased risk of infection. Clinicians should assess the patient for localized erythema, warmth, and discomfort. Patients suspected of having cellulitis or a fungal infection should also be assessed for possible sepsis. Wound cultures have been found to be unhelpful in diagnosing cellulitis. Treatment for cellulitis or fungal infections caused by lymphedema primarily involves treatment of the underlying infection by using antibiotics or antifungals. Treatment and continued management of the underlying lymphedema will also be important to mitigate the risk of reoccurring infection. For patients with recurring infection, prophylactic antibiotic use may be necessary. Meticulous hygiene and attention to even minor breaks in the skin are needed to prevent infection.⁷

Pain and Discomfort

The swelling associated with lymphedema can lead to increased discomfort in the affected extremity. This can be caused by the increased pressure on the nerves and by stretching of tissues beyond their normal physiological limits. Pain caused by lymphedema can be treated through management of the underlying condition. Treating the lymphedema will help to decrease the causative factors of the pain. During treatment of the lymphedema, or in cases where lymphedema is slow to respond to treatments, pain management may be indicated. This can be done through therapy, meditations, lifestyle changes,⁸ or pharmacological techniques. Localized thermotherapy (heat therapy) or cryotherapy (cold therapy) will typically be contraindicated because extremes in temperature can cause increased swelling or negatively affect circulation. Recurrence of cancer may need to be ruled out in some cases.⁸

Range of Motion and Activity Level

Lymphedema can also cause restrictions on movement. As tissues become edematous, especially in areas near or on joints, the angle at which the joint may be manipulated, both passively and actively, may become physiologically limited. This will cause decreased range of motion leading to possible disruptions of activities of daily living. When the hands are affected or the weight of the arm or leg exceeds strength, then self-care, work, and mobility can be affected. Increasing the range of motion in the affected extremity or extremities will be highly dependent on reducing the localized edema. This can be done through treatment of the underlying lymphedema with manual lymphatic therapy or compression dressings, stockings, or sleeves. These treatments can address the immediate limitations to movement; however, range of motion, strength, balance, and use of adaptive equipment may need to be addressed by a physical therapist and/or occupational therapist.

Cancer Risk

A rarer, but more severe, complication of lymphedema is the increased risk of cancer in the affected extremity.^1,9 This is primarily the result of decreased immune surveillance and can include a variety of neoplastic diseases. Treatment of neoplasms that do develop will require the guidance of an oncologist and may include chemotherapy, radiation therapy, and surgical interventions. The primary consideration for most clinicians will be careful assessment of the extremity affected by lymphedema to assist in the early detection of potentially cancerous lesions to facilitate the best outcome.

Conclusion

The main complications of lymphedema include wound healing complications, increased risk of infection, pain, limited movement, and, in rare cases, the development of cancers. Treatment of the underlying lymphedema should typically be the first consideration, with potential treatment options including manual lymphatic therapy, compression devices, exercise, elevation of the extremity, or surgery. Treatment of the symptoms or side effects of lymphedema should be managed during and following treatment of the lymphedema.

References

1. Gordon KD, Mortimer PS. A guide to lymphedema. Expert Rev Dermatol. 2007;2(6):741-752.

2. Scantling D, Pontell ME, Pedevillano L, Jacob TC Jr, Guilday R. Massive localized lymphedema: wound reconstruction with extracellular matrix. Wounds. 2017;29(4):E22-E27.

3. Fu MR. Breast cancer-related lymphedema: symptoms, diagnosis, risk reduction, and management. World J Clin Oncol. 2014;5(3):241-247.

4. Zuther JE. Lymphedema Management: The Comprehensive Guide for Practitioners. New York, NY: Thieme; 2005

5. American Academy of Dermatology. Cellulitis. https://www.aad.org/public/diseases/rashes/cellulitis. Accessed May 6, 2019.

6. Al-Niaimi F, Cox N. Cellulitis and lymphoedema: a vicious cycle. J Lymphoedema 2009;4(2):38-42.

7. National Lymphedema Network. Risk reduction practices. 2012. https://lymphnet.org/position-papers. Accessed May 6, 2019.

8. LymphNotes. Pain Management and lymphedema. http://www.lymphnotes.com/article.php/id/192/. Accessed May 6, 2019.

9. Schwartz RA. Stewart-Treves syndrome. Medscape; 2018. https://emedicine.medscape.com/article/1102114-overview. Accessed May 6, 2019.