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Leg Ulcers and Lymphedema - An Overview

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Lymphedema is swelling due to the accumulation of lymphatic fluid. Read the article to know more.

Medically reviewed by

Dr. Sandhya Narayanan Kutty

Published At December 21, 2022
Reviewed AtSeptember 8, 2023

Introduction:

Ulcers are a break in the skin barrier, giving a chance for air and bacteria to enter the area and cause an infection. Leg ulcers can arise due to a number of reasons, such as venous or arterial disorders, diabetes, or in this case, lymphedema. Lymphedema can negatively affect the patient and his self-esteem and significantly reduce the quality of life. This also hinders the patient from working; thereby, this condition is both a medical as well as a psychological problem.

What Causes Leg Ulcers?

The main cause is believed to be group-A bacteria such as Streptococcus and Staphylococcus aureus. The lymphatics affected become dilated and filled with exudates such as neutrophils and monocytes. This leads to the lymphatics becoming occluded and causing proteins, growth factors, interstitial fluid, glycosaminoglycans, peptide moieties, and bacteria to accumulate abnormally. This, in turn, causes increased collagen production by fibroblasts, accumulation of inflammatory cells such as lymphocytes and macrophages, and also the activation of keratinocytes (keratinocytes are the cells responsible for the production of keratin).

This ultimately leads to the accumulation of protein-filled fluid that increases the deposition of ground substance, dermal thickening and proliferation, subdermal fibrosis, and in extreme cases, abscess formation or cellulitis. In addition, chronic lymphedema gives rise to ulcers; this occurs because of inadequate perfusion.

Leg ulcers due to chronic lymphedema can be divided into four stages:

  • Stage 1: In two percent of the cases have lymphorrhea with an ulcerated lesion.

  • Stage 2: In four percent of the cases, established ulcerated lesions.

  • Stage 3: In three percent of the cases, ulceration with a deep sinus tract.

  • Stage 4: In one percent of the cases, ulcers develop after excision procedures.

What Are the Risk Factors for Leg Ulcers?

The development of ulcers in lymphedema patients is rare when compared to venous disorders. However, certain reasons can cause ulceration, such as lymph trickling (leakage of light amber-colored fluid called lymph from the skin), lymphangiectasia (a rare disorder characterized by lymph leakage due to dilated intestinal lacteals into the small bowel lumen), inflammation, and pustule formation, infection, skin maceration, hyperkeratosis (thickening of the outer layer of the skin), and papillomatosis (projection of dermal papillae above the skin surface). In patients with lymphedema, the small arteries are damaged.

How to Manage Leg Ulcers In Lymphedema Patients?

Leg ulcers are managed depending on the stage of progression.

Stage 1:

In this stage, the leg ulcers are managed conservatively. The ulcers will heal entirely after bed rest, wound dressing, and elevation of the limb.

  • Medications: Antibiotics are administered along with Diethylcarbamazine citrate (DEC). Local antibiotic ointment VAC is also helpful.

  • Skin Care: Managing the skin in ulceration is a crucial part. This includes moisturization to ensure hydration. The dressing should be appropriate to ensure maceration does not occur.

Stage 2:

In stage 2, the ulcers require surgical intervention in addition to conservative management.

  • Surgical Management: The ulcer is debrided, and skin grafting (using split-thickness graft) is done to cover the area. The patient may need three to four weeks of hospital stay. Post-operatively the limb should be cared for to prevent recurrent ulcers.

Stage 3:

The complication with this stage is that even though the ulcers look small, the sinus tract may extend deep and may contain necrosed tissue inside. Maggots can form deep in the cavity. These cases require excision along with the sinus tract in a combined procedure.

Stage 4:

  • These ulcers can not heal with traditional methods as they are formed following excision procedures. They also require a prolonged time to heal.

  • Following conservative measurements and split-thickness skin grafting, some of them heal; however, continuous lymphorrhea can lead to maceration of the skin and ulcer formation.

  • Therefore graduated compression therapy is used in the management of this type of leg ulcer. Multilayer lymphedema bandaging (MLLB), such as padding, toe bandaging, and full leg bandaging, can be incorporated to reduce edema and ensure healing. Multilayer bandaging is believed to be more efficient than single-layer bandaging.

  • Exercise and mobility are helpful in patients with lymphedema and ulceration, mostly in patients with MLLB. Movement helps in enhancing the muscle pump and improves lymph flow. The muscle pump has an important role and effect on venous and lymphatic flow. Healing of the ulcer, even after these procedures, will need an extended period of time and require follow-up to prevent a recurrence.

Time Taken for Healing:

In most studies time taken for healing depends on the stage.

  • Stage 1: Ulcers in stage 1 heal in about ten days' time.

  • Stages 2 and 3: These ulcers heal in three to four weeks' time.

  • Stage 4: These may remain as chronic non-healing ulcers in 10 % to 20 % of cases.

Post-Operative Care:

  • The treatment, irrespective of the stage, does not end with the healing of the ulcer. Post-operative care and routine follow-up are of utmost importance.

  • Post-operative care consists of skincare for the affected limb, limb exercises, and compression bandages. Limb exercises help in promoting lymphatic drainage.

  • Antibiotics and Diethylcarbamazine citrate is recommended as a prophylactic measure to treat reinfection and prevent a recurrence.

  • The prognosis of the condition is favorable as long as the patient follows proper post-operative care.

Factors Affecting Treatment:

The proper recognition of the condition is necessary to treat the ulcer effectively. The management requires combined effort, including conservative, surgical and post-operative management. Diagnosis is the most crucial step in recognizing leg ulcers arising from lymphedema. If a patient has been identified with lymphedema, physiotherapy must be done to prevent the development of an ulcer. In patients with lymphedema, proper treatment and prevention of reinfection prevent ulcer formation. It has been observed that inflammatory markers are higher in ulcers in lymphedema cases than in diabetic ulcers. However, the malignant transformation of these ulcers is rare.

Conclusion:

Leg ulcers are rare in patients with lymphedema compared to other conditions, such as venous disorders. However, if a patient is diagnosed with lymphedema, it is best to take proper care to prevent the formation of an ulcer. Depending on the ulcer is divided into four stages, and treatment is also based on the stage of the ulcer. Proper exercise and skin care can prevent ulcer development. In the initial stages, ulcers can be managed conservatively and require only a little time to heal; in advanced stages, it requires surgical management and more time to heal.

Frequently Asked Questions

1.

Does Lymphedema Cause Leg Ulcers?

Yes, leg ulcers can be a possible consequence of lymphedema. The lymphatic system disorder known as lymphedema causes swelling of limbs due to the abnormal accumulation of lymphatic fluid. If the lymphatic system cannot adequately remove fluid from the affected region, it can cause persistent swelling, tissue harm, and the formation of ulcers.

2.

Are Ulcers Related to Lymphedema?

Ulcers can be related to lymphedema, although they are not a direct symptom of the condition. Lymphedema is a persistent health condition marked by the build-up of lymph fluid in tissues and primarily affects the limbs, such as the arms or legs. If left untreated or poorly managed, lymphedema can result in different complications, including ulcers.

3.

How Do You Treat Lymphedema Sores on Legs?

Treating lymphedema sores on the legs typically involves a comprehensive approach that addresses both the underlying lymphedema and the sores' management. Some common treatment options include:


- Compression therapy.


- Wound care.


- Manual lymphatic drainage.


- Exercise and movement.


- Skincare and hygiene.


- Infection management.


- Lifestyle modifications.

4.

How Does Lymphedema Affect Wound Healing?

Lymphedema can significantly affect wound healing. Lymphedema can hinder wound healing by impairing circulation, causing chronic inflammation, promoting fibrosis, increasing the risk of infection, and delaying lymphatic clearance. These factors disrupt the normal healing process, leading to delayed or impaired wound healing in individuals with lymphedema.

5.

Does Lymphoma Cause Leg Ulcers?

Lymphoma typically does not cause leg ulcers directly. Leg ulcers are more commonly associated with other conditions, such as venous insufficiency, arterial disease, or conditions related to poor circulation. However, in rare cases, lymphoma can indirectly contribute to the development of leg ulcers through certain mechanisms like lymph node involvement, compromised immune function, and side effects of treatment.

6.

What Is the Major Complication of Lymphedema?

The major complication of lymphedema is the increased risk of developing infections, particularly cellulitis. The obstruction of lymphatic fluid caused by lymphedema hinders the usual process that supports the immune system. Consequently, the immune response in the affected limb or area of individuals suffering from lymphedema is weakened. Their immune system's decreased function results in increased susceptibility to infections.

7.

What Are the Dangers of Lymphedema in the Legs?

Lymphedema in the legs can pose several dangers and complications, including:


- Increased risk of infections.


- Worsening of lymphedema.


- Reduced mobility and functional limitations.


- Chronic pain and discomfort.


- Skin changes and ulcers.


Proper management and early intervention are crucial in mitigating the dangers of lymphedema in the legs.

8.

Can Lymphedema Be Cured?

A cure for lymphedema is not known at this time. Lymphedema is a condition that demands consistent care and treatment for the remainder of one's life. Individuals suffering from lymphedema can manage and alleviate symptoms, prevent potential issues, and enhance their overall well-being through appropriate treatment and self-care. The main objectives of managing lymphedema include diminishing swelling, enhancing lymphatic circulation, avoiding infections, and improving the overall function of the affected limb.

9.

What Are the Biggest Signs of Lymphoma?

Lymphoma is a form of cancer that specifically targets the lymphatic system, which works closely to protect the body's immunity. Lymphoma can manifest differently in individuals based on the stage and type of the condition. The following are a few frequently occurring indications of lymphoma:


- Swollen lymph nodes.


- Unexplained weight loss.


- Fatigue and weakness.


- Fever.


- Itching.


- Night sweats.


- Loss of appetite.


- Pain and swelling.

10.

What Does Lymphoma Look Like in Legs? What Are the Symptoms of Lymphoma in Legs?

In lymphoma, the cancer starts in the lymph nodes and spreads to other body parts. Lymphoma affecting the legs may present with the following signs and symptoms.


- Enlarged lymph nodes: Enlargement of lymph nodes near the groin or behind the knee may occur due to lymphoma affecting the legs. Firm or rubbery lymph nodes that are swollen can be both visible and detectable through touch.


- Swelling and edema: Lymphoma can cause leg swelling, leading to edema. The affected leg may appear larger than the other leg and feel heavy or puffy.


- Skin changes: In some cases, lymphoma in the legs can cause skin changes. The skin may appear red, inflamed, or discolored in the affected area.


- Pain or discomfort: Lymphoma can cause pain or discomfort in the legs. The pain may be localized to the affected lymph nodes or radiate throughout the leg.


These symptoms can be caused by various conditions, and their presence does not necessarily indicate lymphoma.

11.

Which Is the Most Worsening Factor for Lymphedema?

The accumulation of surplus lymphatic fluid is generally the most aggravating factor of lymphedema. When the lymphatic system is impaired, as seen in primary or secondary lymphedema, it can hinder lymphatic drainage causing a build-up of proteins, fluid, and waste substances in the tissues. The swelling and inflammation worsen due to fluid accumulation, further exacerbating the symptoms. This then forms a vicious cycle with fluid buildup, creating added pressure on the neighboring tissues and structures, worsening the lymphatic functionality and increasing the symptoms.

12.

What Is the Best Skin Cream for Lymphedema?

When choosing a skin cream for lymphedema, it is vital to prioritize moisturizers that are gentle, hydrating, and suitable for sensitive skin. A few things to check when selecting a skin cream for lymphedema include:


- Fragrance-free and hypoallergenic.


- Moisturizing and emollient.


- pH balanced.


- Non-greasy and fast-absorbing.


- Recommended by healthcare professionals.

13.

Can I Stop Lymphedema Getting Worse?

While lymphedema is a chronic condition that cannot be cured entirely, several steps can help manage and prevent the worsening of lymphedema.


- Follow a comprehensive treatment plan.


- Practice good skincare.


- Wear compression garments.


- Exercise regularly.


- Avoid heat and extreme temperatures.


- Maintain a healthy weight.


- Protect against infections.


- Monitoring for signs of infection.

14.

How Can a Leg Ulcer Be Healed as Quickly as Possible?

- The fastest way to heal a leg ulcer involves seeking medical evaluation for appropriate treatment, including wound dressings, compression therapy, and infection control.


- Wound debridement, if necessary, can remove dead tissue.


- Lifestyle modifications that support healing include quitting smoking and a healthy diet.


- Offloading techniques relieve pressure.


- Regular follow-up and adherence to the treatment plan are crucial.


- Healing time varies depending on the ulcer's severity, underlying conditions, and individual factors.


- Patience, consistent wound care, and close communication with healthcare professionals are essential for optimal healing outcomes.

15.

Is Lymphedema in Legs Reversible?

Lymphedema is a long-term condition, and a complete reversal of the condition is unattainable. Once lymphedema develops in the legs, the damage to the lymphatic system is typically permanent. However, it is possible to manage and control the symptoms of lymphedema, reduce swelling, and improve quality of life through various treatment approaches.

16.

Does Leg Lymphedema Resolve Completely?

Leg lymphedema is a persistent health issue usually long-lasting and has no cure. It cannot be reversed completely once the lower limb’s lymphatic system is impaired. The signs of leg lymphedema can be successfully monitored and alleviated by employing suitable care and therapy. Various methods such as applying pressure, Manual Lymphatic Drainage (MLD), physical activity, skincare, and adjustments to one's lifestyle can help reduce swelling, enhance lymphatic circulation, and avoid complications associated with lymphedema. These treatments alleviate symptoms, slow the disease’s progress, and improve the individual's general well-being.

17.

Is Lymphedema Lifelong?

Yes, lymphedema is typically a chronic condition that persists throughout a person's life. Once lymphedema develops, it is generally considered a long-term or lifelong condition. The damage to the lymphatic system or its impairment cannot be fully reversed, and the underlying causes of lymphedema, such as damage to lymph nodes or vessels, may not be curable.

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Dr. Sandhya Narayanan Kutty
Dr. Sandhya Narayanan Kutty

Venereology

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