How can I help my patient with chronic lymphoedema?
QFifteen years ago my 50-something patient developed chronic lymphoedema below the knee in one leg for no apparent cause. She gets recurrent cellulitis with systemic upset, although she wears a support stocking. She has had fewer episodes since taking penicillin V 250mg daily but they still recur several times a year. How could I prevent this? Is it possible to improve the cosmetic appearance?
AGiven the timescale and lack of a precipitating cause, this is likely to be late onset primary lymphoedema. Treatment consists of reducing the volume of the leg and then maintaining the reduction.
Complex decongestive therapy consists of manual lymphatic drainage (specific physiotherapy to drain lymph away from affected areas), multi-layer short stretch bandages, and exercises.
Once the leg is restored as far as possible to normal size, shape and appearance, the maintenance phase begins.
The patient or carer can be taught a simplified version of the physiotherapy, which combined with compression stockings, exercise and elevation, is used to prevent fluid re-accumulation.
External compression devices can be used as an adjunct.
Minor degrees of lymphoedema can go directly to the maintenance phase without needing intensive treatment to reduce limb volume. Provision of lymphoedema treatment is patchy.
Infection, usually streptococcal, is a common and potentially serious problem.
In addition to prophylactic penicillin it may be worth prescribing a course of antibiotics such as co-amoxiclav 625mg tds for 14 days for the patient to keep and start taking the moment signs of infection flare up.
Tinea pedis is common and provides a portal of entry for infection.
Treatment with antifungals is likely to reduce the frequency of infections.