Leg Ulcers and Lymphedema - An Overview

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.

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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.