Chronic edema and skin infections go hand-in-hand. Chronic, un-resolving edema may have many causes- including, but not limited to dependency/immobility, Chronic vascular insufficiency, diabetes, CVA, lymphedema, renal or cardiac disease, and so on. Given the prevalence of these conditions amongst our patients, it goes without saying that we encounter clients with chronic edema… a lot!
Treating swelling is an important part of the plan of care, and cannot be overlooked for a patient under our care. However, and area that, as clinicians, we should also be keenly aware of- are the skin infections that this client is much more likely to encounter as a result of their chronic edema.
When working with a patient with chronic swelling, we should be sure to educate them about various infections that they may have a high risk of developing. This way, the client will be alert to potential signs of skin issues and seek medical treatment/pause their edema management program.
So, first- why is a person with chronic edema more likely to develop various skin infections? To answer this, we have to look at the processes involved in chronic swelling. Swelling often initially develops as an inflammatory response to an insult or trauma- and in a functional system, the lymphatics will kick into gear to move this fluid, returning it back into the lymphatic system for cleansing and eventually the circulatory system where it is eliminated naturally.
The lymphatic system also has a vital role in fighting disease and infection, through the movement and monitoring of lymph fluid. When this system is overwhelmed (by chronic edema) or impaired, it is not effective in countering disease. This again leads to a predisposition to developing skin infections.
If, however, the fluid remains in the tissues (lymphostasis), it can cause complicated skin issues. This is in large part owing to the content of that lymphatic fluid. The purpose of the lymphatic fluid is to transport various molecules from the tissues, including protein, fatty acids, cells and particles, bacteria, fungal/dirt and dust spores, cancer cells and other inflammatory substances, and any other cells that may require cleansing or transport out of tissues for a healthy system.
Confusingly, the presence of edema in the tissues (lymphatic congestion) can often present as reddened/darker skin, with pain, heat, and swelling. This can make it trickier to parse apart actual infection from congestion. Congestion requires edema management, whereas infection requires medical attention as well as ongoing skin and swelling treatments.
As a result of this lymph fluid stagnating in the interstitial spaces and tissues of peripheries, skin infections may develop in response to the inflammatory properties of the lymph and the molecules with it.
So what skin infections are you likely to encounter when working with a person with chronic edema? Let’s take a look at the 7 most common skin infections you should know about, and be educating your patients/caregivers about as well!
The most common of the skin infections that affect those with chronic edema and lymphedema is cellulitis. Cellulitis is a bacterial infection, which can either enter through a break in the dermis or through an area of inflamed tissue. Many people with chronic edema or lymphedema may experience this skin infection as a recurring condition, that can arise when their limb is particularly congested or swollen.
Signs of cellulitis includes: a feeling of general malaise, fever, pain, nausea/vomiting; a red or purplish, painful, and swollen rash in the affected region, which may spread if left untreated. It is important to reassure your patient that this infection in non-contagious, which may be a distressing thought to them.
Treatment of cellulitis is urgent- left unattended, it has the capability to spread further into the skin and tissues, cause serious illness, and further impair the lymphatic system in the region, which will lead to long term swelling (and in turn, a higher risk for future cellulitis). We can see now why cellulitis can recur so frequently in those with chronic edema.
The borders of cellulitis are diffuse and can reach into lower layers of skin and tissue than other infections. It may also spread along tendons and muscles.
Cellulitis requires immediate antibiotic administration to heal. As a clinician you should advise your patient to demarcate the edges of the rash, and be able to report as to whether it has spread (and how quickly). Compression can also help to prevent further swelling, help the infection clear more quickly, and reduce pain- Although, if the person is participating in an edema management program involving the use of manual lymphatic drainage.
For more information about the diagnosis and treatment of cellulitis in those with chronic edema, read the British Lymphology Society Consensus Document on Cellulitis.
Also a common skin infection affecting those with chronic swelling, erysipelas affects the superficial layer of skin. It is a bacterial infection, similar to cellulitis- however erysipelas affects the skin nearer to the surface, whereas cellulitis often involved deeper tissues and structures. Erysipelas will present as a fiery, red rash, with clearly delineated (sometimes referred to as “map-like” borders).
Erysipelas bacteria may also enter through a break in the skin, such as an abrasion, insect bit, ulcer, or burn. Signs of erysipelas are a raised, bright red (not dark) rash, with clear and sharp borders. It can spread if left untreated, and as before, can become a recurring condition for a client already predisposed to infection.
Erysipelas is treated with antibiotics, either oral or IV (depending on the severity of the condition). Treating the edema through elevation, cold packs, and compression will also help with clearing the infection.
Lymphangitis, an inflammation of the lymphatic system and channels. Infected lymph fluid travelling through the lymph vessels is the cause of lymphangitis, and also its defining characteristic.
An infection enters the lymphatic channel through a wound or skin break- commonly an insect bite, or a large abscess that is facilitating an inflow of bacteria into the lymphatic system. Chronic lymphangitis may also occur as a result of recurrent acute bacterial lymphangitis infections.
Lymphangitis presents as a red streak or several red streaks spanning from the site of open skin, which ay be warm, are soft and not raised, tender, and swelling. The person with lymphangitis may feel feverish/flu-y, malaise, elevated pulse, and sometimes enlarged lymph nodes.
Antibiotics are used to treat lymphangitis, and the person should be educated to monitor for worsening swelling after the course of the antibiotics, as the lymphatic system may be impacted and at risk for future lymphedema.
Folliculitis is an infection and or irritation of the hair follicle. Damaged follicles may the site of a bacterial infection, complicating the folliculitis further. It has been linked in those with chronic edema to Intermittent Pneumatic Compression, lack of skin care, use of hot tubs, or shaving of curly hairs and subsequent ingrown hairs.
Though not excessively major as an infection, folliculitis has the possibility to develop into a more serious condition, especially if affecting a person with lymphedema/chronic swelling. Folliculitis usually will present as tiny red or white bumps around the hair follicle, which can become pustulus, itchy, and painful.
This condition can be prevented in those with chronic edema by avoiding tight clothes; not shaving arms/legs, or shaving with care; meticulous skin care and use of barrier cream; avoiding hot tubs and heated pools.
Fungal infections can occur commonly in Stage 2 and Stage 3 lymphedema. In chronic edema, skin may lose its architecture and skin folds can develop- which are dark, moist breeding grounds for fungal growth. Infections may also pop up on the skin as a result of skin conditions such as hyperkeratosis or papillomatosis, which can hold moisture and can lead to fungal infection.
As people with chronic edema and lymphedema may have difficulty with adequate washing and drying of their feet and toes, fungal infections may set in here also. These infections are highly contagious and can be transferred by infected footwear, socks, and liners.
Signs and symptoms of fungal infections include irritation, scaly rash, greenish discoloration, redness and itchiness, a distinctive odor, and blistering.
Prevention of fungal infections are the best treatment, as with most infections. Meticulous skin hygiene, towel drying, use of anti-fungal sprays and powders can help to prevent fungal infections from setting in and occurring. If an infection has set in, a physician must be consulted, and medicated creams may be prescribed to treat the infection.
Contact dermatitis is an infection that can occur as an allergic reaction to a foreign or irritating substance. In people with chronic edema, it can occur as a reaction to bandaging, use of pumps, or other irritants.
It presents as itchy, red, swollen, inflamed skin, which may feel as though its burning or tender. The skin can become very dry, which may lead to cracking or tightness and even blistering.
Treatment for contact dermatitis, especially for those getting treatment for lymphedema, it is beneficial to use barrier lotions and creams between dressings and bandages; anti itch creams; identification of the irritant and avoiding of it when possible; steroid creams and possibly oral medications.
Skin infections and issues are to be expected when working with clients who have chronic edema, and as clinicians it is imperative to include education about this when we work with out clients with chronic edema.
This is a topic that I routinely address several times to make sure that the person is aware of varying signs and symptoms to look for, when to seek medical advice and how to increase comfort at home, and- importantly- how to avoid the development of these common skin infections in the first place, if possible.
Want to learn more about types of swelling, assessment, creating a plan of care, and providing effective management? Check out our ever popular course, Edema Management in Inpatient Rehab for a comprehensive, practical information. You are going to love the hands-on, evidence based techniques that you can use to greatly improve your patient outcomes!
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