It's all too common to have swollen ankles towards the end of a long day - but what if the swelling doesn't go down? What if it's your arms that are affected too? Lymphoedema and the rarer lipoedema could just be to blame. If you push your thumb into an area of lymphoedema, you'll usually get a dent in the skin. This doesn't happen with lipoedema.
What causes lymphoedema?
Your lymphatic system is like a miniature railway - a network of lymph ducts connected at 'stations' called lymph nodes or glands. It plays a major part in transporting white blood cells around your body to fight infection - the swollen glands you get in your neck when you have a sore throat are lymph nodes full of white blood cells. It also carries excess fluid away from your body tissues.
'Oedema' is the medical term for some kinds of swelling. Lymphoedema is swelling, often in your leg(s) or arm(s), caused by abnormal drainage in your lymphatic system. To begin with, the swelling may settle overnight but as time goes on, it becomes more constant, especially without treatment.
There are two main kinds of lymphoedema. 'Primary' lymphoedema isn't triggered by anything and is caused by faulty genes which mean your lymph system doesn't develop properly. It often runs in families.
'Secondary' lymphoedema is much more common - it's caused by blockage of, or damage to, your lymph channels. Causes include:
- Removing lymph nodes during cancer surgery (particularly for melanoma and cancer of the breast, cervix, vulva, prostate and penis).
- Radiotherapy treatment for cancer.
- Infection - most commonly cellulitis, although a parasitic infection called filariasis is common in other countries.
- Past trauma causing damage to the lymphatic system.
- A deep vein thrombosis, in which a vein or veins carrying blood back to the heart (usually deep in the calf) become blocked off.
- Inflammation from other conditions such as severe eczema or rheumatoid arthritis.
- Being very overweight or immobile.
What are the symptoms of lymphoedema?
Lymphoedema can give rise to:
- Uncomfortable swelling in part of all of the limb that's affected. To begin with the swelling may settle overnight and become more noticeable as the day wears on.
- Restriction of movement.
- A sensation of heaviness or aching of the limb.
- The skin (and jewellery or clothes you put on it) feeling tight.
- Leaking of clear fluid from the skin.
- Thickening of the skin.
But the main complication is skin infection called cellulitis. Red, hot, swollen, painful patches of skin are often accompanied by fever and feeling generally unwell. See your doctor for advice and assessment if this happens to you.
How is lymphoedema diagnosed?
If you have had surgery for cancer and have developed swelling in a nearby limb (for example, an arm following breast cancer surgery) your doctor may be able to make the diagnosis based on your symptoms and examining you. Your doctor will measure the circumference of both limbs to see if one is enlarged.
Sometimes you may need other tests. For instance, your doctor may arrange:
- Blood tests and a specialised ultrasound scan to exclude a deep vein thrombosis (a clot deep inside the limb).
- An MRI or CT scan to see if cancer is blocking the lymph nodes.
- A scan called a lymphoscintigram, which uses radioactive dye to check movement of lymph through your lymphatic system.
- Perometry - a method of measuring the volume of a limb using infrared light.
What are the treatments for lymphoedema?
Treating symptoms of lymphoedema
A combination treatment called decongestive lymphatic therapy may be recommended. This is usually initiated and monitored by specialist clinics and includes:
- Regular exercises of the affected limb(s), which can improve lymphatic drainage.
- Compression bandages to help improve the drainage of lymphatic fluid, and cut the degree to which it recurs.
- Manual lymphatic drainage - a specialised form of massage, designed to stimulate lymphatic drainage.
- Skin care to reduce the risk of the skin infection called cellulitis.
The National Institute for Health and Care Excellence (NICE) has produced guidelines stating that there is strong enough evidence for liposuction to be recommended for some patients with chronic lymphoedema. They must be chosen by a multidisciplinary team as part of a lymphoedema service. See recently updated recommendations in Editor's Note below:
Dr Krishna Vakharia, 10th May 2022
Liposuction for lymphoedema - is recommended by NICE
NICE has now published guidance on the use of liposuction for people with chronic lymphoedema. They have found that liposuction offers:
- A reduction in limb volume (the size of the limb).
- An improvement in quality of life such as feelings of discomfort, limbs being symmetrical and improvements in mobility.
- A reduction in cellulitis (skin infection).
They also found that these changes with liposuction were long-lasting.
However, this treatment does have potential risks. These include deep vein thrombosis and fat embolism (where fat travels in the bloodstream and lodges elsewhere in the body).
For these reasons, NICE recommends liposuction for people with chronic lymphoedema only if all standard treatments have not worked. It can only be recommended by a multidisciplinary team in specialist centres. See Further Reading and References below.
Avoiding complications from lymphoedema
Taking special care of your skin is very important to reduce the risk of infection. If your feet are affected, regular visits to a podiatrist will help. If it's one arm, avoiding tight jewellery, blood pressure readings or injections on that side are all important.
As a general rule, tips to avoid infection if you have lymphoedema include:
- Keeping your weight down.
- Properly fitted shoes that don't rub if you have lymphoedema of the feet.
- Using insect repellents to avoid insect bites.
- Regular moisturising.
- Avoiding very hot baths (and sauna and steam baths); and
- Using an electric razor to avoid razor cuts.
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What is the outlook for lymphoedema?
In the early stages, it may be possible to reverse lymphoedema, especially if any blockage can be cleared. However, following cancer surgery this may not be possible. As time goes on, the tissues in the affected area become damaged, so lymphoedema cannot be cured. However, treating lymphoedema with regular lymphatic drainage and compression, and taking steps to avoid complications, can often prevent it from worsening.
What causes lipoedema?
Lipoedema is an abnormal build-up of fat cells, and it's almost exclusively a female condition. Unlike lymphoedema, it isn't caused by surgery or infection - it often runs in families and tends to develop when your hormone levels are fluctuating (puberty, pregnancy, menopause).
We tend to think of fat cells as being associated with being overweight. In fact, while lipoedema is made worse by carrying excess weight, many women with lipoedema are within the normal weight range.
What are the symptoms of lipoedema?
Lipoedema most commonly affects the whole of both legs and less often arms. It may look as if your legs, hips and buttocks are out of proportion with the rest of your body. It may start at around puberty, or possibly during pregnancy. However, lipoedema does not affect feet or hands. This means that it may look as if there is a band or bracelet around your ankles or wrists.
As well as being swollen, your legs may feel achy, and you can develop small broken blood vessels or bruising. You may develop restriction of movement in your limbs and find it difficult to keep active.
In some cases, this can lead to low mood or even depression.
How is lipoedema diagnosed?
Your GP will ask you questions and examine you. In particular, they will be looking for:
- Disproportionately large legs compared to your feet or the rest of your body.
- Soft, cellulite-like fat on both legs (or arms).
- Tenderness over the skin.
- Easy bruising to the skin of the affected areas.
Because lipoedema often runs in families, it is important to explain to them which, if any, members of your family (almost always female) are affected.
Are any further tests needed?
Your doctor may want to refer you for the tests used to diagnose lymphoedema (above) to see whether your symptoms are caused by lipoedema. They may refer you to a specialist lymphoedema clinic. The staff here can help confirm the diagnosis. They can also help with treatment, both to improve your lipoedema and to prevent lymphoedema developing.
What are the treatments for lipoedema?
Unlike lymphoedema, losing weight makes little difference to lipoedema. Neither do 'water tablets' or keeping your legs raised - both of which can be very helpful in other forms of oedema.
There are two main groups of treatment for lipoedema, which can be helpful in lymphoedema too. The first is non-surgical. Compression garments don't affect the fatty tissue much but they can reduce swelling and discomfort. Low-impact exercise like swimming and massage can also help.
However, the only way to get rid of the fat cells that cause lipoedema is a form of liposuction. Unfortunately, you may need several operations and it's not usually available on the NHS.
Dr Sarah Jarvis, 31st March 2022
Liposuction for lipoedema - not recommended by NICE
The National Institute for Health and Care Excellence (NICE) has published guidance on the use of liposuction for people with chronic lipoedema.
They have found concerns that liposuction could lead to complications, including deep vein thrombosis and fat embolism (where fat travels in the bloodstream and lodges elsewhere in the body).
They also found that the evidence that liposuction is effective is limited. For these reasons, NICE does not recommend liposuction for people with chronic lipoedema except as part of a research study. See Further Reading and References below.
What is the outlook for lipoedema?
It is important to see your doctor if you think you might have lipoedema or lymphoedema. Without treatment, people with lipoedema can go on to develop lymphoedema. Lymphoedema and lipoedema can be distressing conditions, and being affected can affect your mental well-being. While neither condition can be cured, there is support out there that can make a big difference.
Further reading and references
Liposuction for chronic lymphoedema; NICE Interventional procedures guidance, August 2017
Liposuction for chronic lipoedema; NICE Interventional procedures guidance, March 2022
Liposuction for chronic lymphoedema; NICE Interventional procedures guidance, April 2022
Decongestive lymphatic therapy for patients with cancer-related or primary lymphedema; American Journal of Medicine