Have you seen these skin changes with your patients?

Skin Changes associated with Chronic Edema

Many therapists and nurses notice some strange and characteristic skin changes occurring with their patients with chronic edema and lymphedema. Here, we go over 4 distinctive skin changes that you may encounter, and briefly discuss what types of treatment approaches you would include to manage and treat these conditions. To read more about types of swelling that can lead to these skin conditions, read our popular post: 7 types of swelling nurses and therapists should know about!

There are many distinctive skin changes associated especially with the later stages of lymphedema. But why do these changes occur, what are they, and what can we do to address them?

Well, lets consider first what is in the lymphatic fluid that is the source of the swelling.

Lymphatic fluid is made up of water, protein, white blood cells (lymphocytes), cell debris, hormones, fatty acids, and other dirt/dust/fungal spores that the nodes filter and discard to keep us healthy. So as you can see, it isn’t exactly filtered mountain-stream water!

There is a body of research indicating that the lymphatic fluid that is remaining static and collecting in our limbs, such as it is in those with lymphedema, leads to a number of skin changes because of the composition of the lymphatic fluid. Considering the make-up of this fluid, and the less-than-pleasant molecules that travel around in lymph before it gets cleaned and filtered at the nodes, is it any wonder that  characteristic and unusual skin changes can bloom? Growth factor adhesions, fibrin cuffs, cytokines, and white blood cell trapping from stagnant lymphatic fluid may lead to some of the changes we discuss, such as overgrowth of the epithelial layer (hyperkeratosis, papillomatosis), and fibrosis. Stretched, ruptured and broken lymphatic vessels lead to lymphorrhea. Let’s discuss some of the skin changes in more detail, and talk about how we can help treat them.

1. Lymphorrhea

Lymphorrhea is caused by broken or ruptured lymphatic channels that leak lymphatic fluid through the skin. It may be caused by increasing pressure within the limb from chronic lymphedema, and can also be seen post-surgery as the local edema around the wound puts pressure on the skin, and lymphatic channels do not close adequately. In those with lymphedema, a tiny abrasion, wound or cut can lead to leaking of lymphatic fluid through the skin. As it is toxic to the skin, lymphorrea can cause skin breakdown and maceration, and lead to non healing wounds.

In the treatment and management of lymphorrea, you should ensure to clean the skin meticulously. As mentioned, lymphorrea is an irritant to the skin and so the skin should be cleaned of any fluid traces. Once the skin is clean and dry, soft materials and absorbent wound dressings should be used to help reabsorb the lymph and protect the skin. This will also help to avoid maceration and further breakdown of the skin. The dressings should be wrapped on with a short stretch bandaging complex as used in Complete Decongestive Therapy. Manual Lymphatic drainage techniques will help to move stagnant fluid and decrease the pressure within the limb that may be pushing fluid onto the skin surface.

A person experiencing lymphorrhea should be educated to beware for cellulitis, as it can occur as a result of the drainage. Bacterial colonies may also form in the wound if proper hygiene and wound care is not observed.

Lymphorrhea responds extremely well to Complete Decongestive Therapy and you may expect to see lymphatic closure and recovery within 24-48 hours of treatment. Continued treatment and use of compression will help this symptom from re-occurring, although it is not uncommon for this to be experienced by many people living with lymphedema from an accidental scrape or cut.

2. Fibrosis

Fibrosis is a progressive thickening, scarring and hardening of the skin. The fibrous connective tissue in the skin and superficial tissues grows and proliferates, leading to extensive hardened, scarred tissue over the affected extremity.

Fibrosis build up is common with limbs affected by lymphedema, as the protein-rich lymphatic fluid builds up and hardens. The development of fibrosis is seen more commonly in middle to later stages of lymphostasis, and leads to many skin integrity issues and complications. Skin will break down more easily if it is fibrotic as there is no natural “give” to the skin that comes into contact with objects. Bacterial infections and cellulitis are more common and more difficult to treat secondary to the lack of circulation and fluid movement in the limb.

Fibrosis requires manual manipulation, myofascial release and Complete Decongestive Therapy to be treated effectively. ‘Rolling’ the skin, releasing the hardness through manual edema mobilization and myofascial release can help to make the skin more pliable and soft. Using chip pads and varying densities of foams under the short stretch bandaging complex can help to increase the surface area and provide continuous mobilization and release to soften and mobilize the skin. Fibrosis responds well to this treatment and can be effectively softened, allowing the skin and the tissues to receive more nutrients and become healthier.

3. Papillomatosis

Papillomas are a benign overgrowth of the skin papillae (the extensions of dermis into epidermis), and mucous membrane- collagen plaque buildup in the skin leading to ‘bubbling’ overgrowth on the surface. Papillomas are highly vascularized and bleed easily if irritated. They can be a source of infection if opened and can lead to bacterial infection and cellulitis. Papillomatosis is likely related to the content of the stagnant lymphostatic fluid. Papillomas can become fibrotic and harden is left untreated, which leads to more complications when treating and managing these areas. Treatment for fibrotic areas follows similar guidelines to the above, though more caution should be taken with myofascial release and rolling secondary to the sensitive skin that may be under a papilloma.

When softened, many papillomas will shrink away and reabsorb with appropriate Complete Decongestive Therapy.  Use of soft cotton and foam can help soften these regions, provide comfort and support and keep skin integrity. Owing to their chronic nature, some papillomas require surgical removal- though recover post surgery will be hastened if Complete Decongestive Therapy is completed prior to surgery.

4. Hyperkeratosis

Hyperkeratosis is an overgrowth of the epithelial layer of the skin, leads to depositions of layers of skin on top of itself or an over-proliferation of thickened skin. Keratin in the skin has a protective function, but when in over abundance can harden and thicken the outer layer of skin. Hyperkeratosis often has a granular layer build up that can contribute to these skin changes. Hyperkeratosis at the toes and feet often can appear as warts and calluses, whereas hyperkeratosis on the shins appears as dry layers of flaky skin. Like papillomatosis, this is highly vascularized and should not ever be mechanically debrided as open areas will ensue. Accumulation of hyperkeratosis can inform fungal infections secondary to moisture in the region.

Hyperkeratosis can respond well to Complete Decongestive Therapy, with compression and manual manipulation (as in the treatment of fibrosis) used in softening the skin, and lotions such as ammonium lactase and oil emulsion used to soften the callused tissue.

These skin changes, though they can appear to be intimidating and chronic, can have excellent results when treated with Complete Decongestive Therapy! Skin care, manual edema mobilization, compression bandage complexes show remarkable results in treating and reducing all of these severe lymphostatic skin changes.

Learn how to incorporate a lymphedema approach into edema management in in-patient for all types of edema and chronic skin integrity issues. Our popular course, “Edema management in In-Patient Rehabilitation”, has yielded excellent results with clinicians using these techniques, and can benefit any therapist or nurse, no matter where you work!

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