best practice for the management of lymphoedema ... - EWMA

FIGURE 13 Hyperkeratosis FIGURE 14 Folliculitis
Hyperkeratosis
Hyperkeratosis (Figure 13) is caused by
overproliferation of the keratin layer and
produces scaly brown or grey patches.
Emollients with a low water content are
recommended. MLLB reduces the
underlying lymphoedema and improves skin
condition. If the condition has not improved
within one month, the patient should be
referred according to local dermatology
guidelines.
Folliculitis
Folliculitis (Figure 14) is due to inflammation
of the hair follicles. It causes a red rash with
pimples or pustules, and is most commonly
seen on hairy limbs. The cause is usually
Staphylococcus aureus, and it may precede
cellulitis/erysipelas. Swabs should be taken
for culture if there is any exudate or an open
wound.
An antiseptic wash/lotion, eg one
containing chlorhexidine and benzalkonium,
should be used after washing. Emollient
should be applied without being rubbed in. If
there is no response after one month, the
patient should be referred according to local
dermatology guidelines.
Fungal infection
Fungal infection (Figure 15) occurs in skin
creases and on skin surfaces that touch. It
causes moist, whitish scaling and itching,
and is particularly common between the
toes. It can precede the development of
cellulitis/erysipelas. Skin scrapings and, if
nails are affected, nail clippings should be
sent for mycological examination.
FIGURE 15 Fungal infection on
the sole of the foot
Treatment is with terbinafine 1% cream
for up to six weeks alongside meticulous
skin care. In some countries, Whitfield
ointment is used as an alternative. Any
sign of bacterial infection should be
treated promptly (pages 27-29). Nail
infection requires treatment with an oral
antifungal agent under medical
supervision. The patient should be referred
to a dermatologist if there is no response
after six weeks' treatment.
Lymphangiectasia
Lymphangiectasia (Figure 16 – also known
as lymphangiomata) are soft fluid-filled
projections caused by dilatation of
lymphatic vessels. Treatment is
compression with MLLB. If there is no
response to initial compression, or the
lymphangiectasia are very large, contain
chyle or cause lymphorrhoea, the patient
should be referred immediately to a
lymphoedema practitioner with training at
specialist level.
Papillomatosis
Papillomatosis (Figures 17 and 18)
produces firm raised projections on the
skin due to dilatation of lymphatic vessels
and fibrosis, and may be accompanied by
hyperkeratosis.
The condition may be reversible with
adequate compression. If the condition
does not improve after one month, the
patient should be referred to a
lymphoedema practitioner with training at
specialist level.
SKIN CARE
FIGURE 16 Lymphangiectasia
FIGURE 17 Papillomatosis
FIGURE 18 Severe papillomatosis
BEST PRACTICE FOR THE MANAGEMENT OF LYMPHOEDEMA 25