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Lymphland International Lymphedema Online
| Codes for Cellulitis Arm 682.3 Finger 681.00 Foot 682.7 Hand 682.4 Leg 682.6 Neck 682.1 Toe 682.10 Torso 682.2 THESE LETTERS MAY REFER TO: C COMBINED, COMPLETE, OR COMPLEX D DECONGESTIVE P PHYSIOTHERAPY OR PHYSICAL THERAPY L LYMPHEDEMA OR LYMPHATIC ABBREVIATIONS CDP COMPLETE OR COMPLEX DECONGESTIVE PHYSIOTHERAPY (USED BY MEDICARE FLORIDA) CPDT COMPLEX PHYSICAL DEONGESTIVE THERAPY (FOLDI, GERMANY) CPT COMPLEX PHYSICAL THERAPY (CASLEY-SMITH, AUSTRALIA 1980) CLT COMPLEX LYMPHATIC THERAPY (CASLEY-SMITH, AUSTRALIA) CDT COMBINED DECONGESTIVE THERAPY (VODDER) LT LYMPHEDEMA THERAPY LMT LYMPHEDEMA MULTIMODAL THERAPY * NOTE IT ALSO STANDS FOR LICENSED MASSAGE THERAPY/THERAPIST AS WELL MLD MANUAL LYMPH DRAINAGE (ORIGINALLY VODDER) MLT MANUAL LYMPH/LYMPHATIC THERAPY/TREATMENT/TECHNIQUE (USED IN SCIENTIFIC MAGAZINES) LDT LYMPH DRAINAGE THERAPY (CHIKLY) MLDT MANUAL LYMPH DRAINAGE THERAPY, A COMBINATION OF THE ABOVE THE FOLLOWING TERMS SHOULD NOT BE USED IF POSSIBLE LM LYMPHATIC MASSAGE LDM LYMPHATIC DRAINAGE MASSAGE MLM MANUAL LYMPHATIC MASSAGE MLDM MANUAL LYMPH DRAINAGE MASSAGE THE WORD "MASSAGE" IS MISLEADING TO PATIENTS AND INSURANCE IN DESCRIBING THE LIGHT AND SPECIFIC TOUCH OF LYMPHATIC DRAINAGE. --------------------------------------------------------- What is cellulitis? Cellulitis, what is it? Cellulitis is an infection of the skin and underlying tissues that can affect any area of the body. Not to be confused with cellulite - the cottage-cheese-like, lumpy fat often found on the hips, thighs, and buttocks, cellulitis begins in an area of broken skin, like a cut or scratch, allowing bacteria to invade and spread, causing inflammation, which includes pain, swelling, warmth, and redness. Cellulitis can be caused by many different types of bacteria, but the most common are Group A Streptococcus and Staphylococcus aureus. In special cases, other bacteria can cause cellulitis. Cellulitis after a cat or dog bite may be caused by Pasteurella multocida bacteria. Cellulitis due to Pseudomonas infection occurs after nail-puncture wounds through sneakers. Other types of bacteria from fish and farm animals can also cause cellulitis. Signs and Symptoms Cellulitis begins as a small, inflamed area of pain, swelling, warmth, and redness on skin. As this red area begins to spread, you may begin to feel sick and develop a fever, sometimes with chills and sweats. Swollen lymph nodes (commonly called swollen glands) are sometimes found near the area of infected skin. Contagiousness Cellulitis is not contagious. If you get a scrape, wash the wound well with soap and water. Apply an antibiotic ointment and cover the wound with an adhesive bandage or gauze. If you notice any symptoms, see a doctor immediately. Cellulitis can spread and invade the blood system and become deadly fast. ++++++++++++++++++++++++++++++++ Common Cellulitis Symptoms by Diane Sievert Cellulitis symptoms are often ignored because many people characterize this infection as nothing more than a rash. As cellulitis symptoms do indeed mirror those of a common rash, it's perfectly comprehensible how this mistake could be made. The main difference between a rash and cellulitis is that cellulitis, since it's a deep tissue infection, generally appears near a wound of some sort. As cellulitis is an infection, the symptoms associated with it are those most often associated with various skin infections. These symptoms include the following: redness, warmth, swelling and pain. If you have a wound or skin trauma of some sort that is exhibiting these common inflammation symptoms, you may have a case of cellulitis. Sometimes noninfected swelling and inflammation problems are taken to be cellulitis symptoms when they are in fact something else entirely. For instance, people who suffer from poor leg circulation can develop a condition called "stasis dermatitis" that is often mistaken for cellulitis because of the scaly red skin it causes. This, however, is only one of many conditions that is often misdiagnosed as cellulitis. Where Do Cellulitis Symptoms Develop? As earlier stated, most cases of cellulitis develop near areas of skin trauma. If you're not sure what constitutes "skin trauma," it includes anything from slight scratches to surgical wounds and ulcers. But do be aware, however, that sometimes cases of cellulitis develop when there is no skin trauma at all. TO TRY TO PREVENT CELLULITIS: Wear gloves when doing housework, gardening, dealing with pets or sharp objects. In the winter time, protect your hands from chapping by using adequate creams/lotions and wear gloves or mittens. Wear long sleeves, pants, shoes, adequate protection from sunburns, scratches, bumps, bruises, etc. Examine your skin daily to make sure there are no irritations, cuts, chapping, or breaks. If you do have a break or irritation, cover it with an antibiotic cream and gauze bandage if possible. Coving the skin will prevent bacteria from entering. LYMPH NODE CULTURES Lymph node culture is a laboratory test performed on a lymph node to identify organisms (bacteria, viruses, and fungus) that cause infection. A needle aspiration or biopsy of an enlarged lymph node(swollen gland) is obtained. The fluid is placed in culture media and observed for growth in the laboratory. Sometimes special stains are also done. The site may be numbed with a local anesthetic before the node is aspirated. There may be some pain when the needle is inserted into the lymph node. The test may be performed if the cause of swollen glands is not known, and infection is suspected. ARE GENERIC ANTIBIOTICS OK TO TAKE FOR CELLULITIS AND INFECTIONS? ‘You can trust any generic drug as much as you trust its brand name equivalent' 26 Jun 2005 The white pill on the left will restore a person's health. The white pill on the right is advertised as being the same drug, but it costs half as much. But are they really the same - and should people be willing to bet their health on the answer? James Adams, Ph.D., associate professor of molecular pharmacology and toxicology for the USC School of Pharmacy, says absolutely - at least in the United States and Canada. “You can trust any generic drug as much as you trust its brand name equivalent,” Adams says. “The U.S. Food and Drug Administration is very strict about quality guidelines in the production of medicines and rarely makes mistakes on that issue. If they find a difference in how the drug is made or works, they pull it immediately.” Generics' lower cost stems from economics, not from second-rate production of the plain-wrap version. Generics may not be made or sold until the manufacturer's patent on the brand-name version expires, giving the company time to recoup its investment in the development and testing of the drug. Once the patent expires, different companies can produce generic versions, and the competition drives down the price. Because of trademark laws, generic drugs are not allowed to resemble brand-name drugs too closely, but Adams emphasizes that there is no difference in quality or effectiveness. He also says that generic drugs purchased in Canada are as good as those from the U.S. - and they are often produced locally by American companies or actually made in the U.S. Generic drugs from Mexico are more risky. But if you have a known sample of a pill and the bottle it came in, and the pharmacy in Mexico can offer you a pill and bottle that match, Adams says, “you can usually trust it.” http://www.usc.edu/ ----------------------------------------------------------------- Infections Related to Lymphedema Introduction Serious infections that can develop within the affected tissues are a serious complication associated with lymphedema. The risk of infection increases when lymphedema is not controlled by proper treatment and appropriate precautions. The risks of lymphedema related infections are due to: The swelling of lymphedema compromises the health of the skin. Healthy intact skin is the body’s primary line of defense against invading pathogens. Normal skin is protected by a film known as the acid mantle. The acidic nature of this film discourages such pathogens. When skin is swollen, the acid mantle is disrupted and is not as effective in stopping invading pathogens. Protein-rich stagnant lymph within these swollen tissues creates an environment that pathogens love! This lymph has nutrients that allow the pathogens to thrive. This stagnant lymph can also contain pathogens and damaging toxins that should have been removed by the normal flow of lymph. The deep skin folds resulting from the lymphedema are an ideal breeding ground for fungal infections. The area within the folds in warm, moist, and dark. This creates an ideal environment for fungi such as tinea pedis (athlete's foot) and tinea cruris (jock itch). Cellulitis Cellulitis (sell-you-LYE-tis), also known as lymphangitis, is an infection that spreads freely, quickly, and uncontrollably within the deeper tissues of the skin. Cellulitis becomes a life-threatening emergency when it spreads through the lymphatic or circulatory systems and can reach vital organs and other body parts. This type of infection requires prompt treatment with antibiotics. Cellulitis is usually caused by the bacteria staphylococcus aureus that normally live on the skin. Any break in the skin, no matter how small, provides an opening for them to march in, multiply, and thrive. Even a simple act such as shaving a swollen leg could be an invitation to infection. Symptoms of Cellulitis Malaise (a general sense of not feeling well) Flu-like symptoms Chills and fever Discoloration (redness, or streaky red lines) Rash Tissues that feel hot and tender Sudden swelling Itching Pain Erysipelas Erysipelas is visible just below the ankle bone. Erysipelas (er-ih-SIP-eh-las) is a painful skin infection that affects the skin plus the subcutaneous tissues and lymphatic structures that are located just under the skin. This is in contrast to cellulitis which thrives within the deeper tissues; however, erysipelas also requires prompt treatment with antibiotics. Erysipelas is caused by the bacteria Streptococci. These pathogens, which normally live harmlessly on the skin, can enter through any break in the skin such as a scratch, pinprick, or the cracks caused by athlete’s foot. Erysipelas invades rapidly and spreads through the lymphatic vessels. This damages the lymph vessels and increases the formation of fibrosis in the affected tissues. This damage further disrupts the flow of lymph. Erysipelas, which is one of the most common complications of lymphedema, tends to recur and there appears to be a correlation between the frequency of erysipelas infection and the stage of lymphedema. Symptoms of Erysipelas An expanding area of redness of the skin that most often occurs in the region of the ankle Itching Pain High fever, and chills Swelling and tenderness of the regional lymph nodes. Lymphangitis Lymphangitis (lim-fan-JIGH-tis) is an infection involving the lymphatic vessels that is most commonly caused by the spreading of an acute streptococcal or staphylococcal infection of the skin. The presence of lymphangitis suggests that an infection is progressing and should raise concerns of spread of bacteria to the bloodstream. Known as sepsis, a bacterial infection in the bloodstream can spread to all of the body systems within a matter of hours. Therefore, at the first signs of lymphangitis, you should seek medical treatmentimmediately . Symptoms of Lymphangitis Malaise, loss of appetite, headache, and muscle aches Red streaks from infected area to the armpit or groin (These may be faint or obvious) Swollen lymph nodes Chills and fever Fungal Infections Fungal infections occur most often when the genitalia, legs and feet are affected by stage 2 or stage 3 lymphedema. Athlete’s Foot, which is caused by the fungus tinea pedis, occurs on the feet and between the toes. Jock itch, which is caused by the fungus tinea cruris, thrives in the genital area. These infections occur when the right combination of conditions exists including A warm, dark humid environment, such as between the toes. Any change in the health of the skin. Lowering of the body's natural resistance. Tinea Pedis Symptoms Pain, burning, and itching Drying, cracking, and scaling of the skin Blistering Swelling These infections are difficult to treat and prevention is the best approach. This includes: maintain cleanliness by changing shoes and socks as often as necessary; controlling moisture by using an antiperspirant powder or spray; and routinely using an antifungal ointment, and/or powder as recommended by your healthcare provider. Jock itch can be treated with over-the-counter ointments; however, it is advisable to see your physician for professional advice. Once the condition is under control, antifungal powders or sprays may be recommended for daily use as a preventive measure. http://www.lymphnotes.com/article.php/id/323/ ............................................................................... Necrotizing Fasciitis and Lymphedema Introduction Necrotizing fasciitis (NF) is a bacterial infection caused by a Group A streptococcus. These bacteria usually cause relatively mild illnesses such as a strep throat. On very rare occasions, these bacteria cause the severe and life-threatening disease known as NF. [1] NF, commonly known as flesh-eating bacteria, can destroy the skin, the fat under the skin, and the adjacent muscle tissues. It also produces gangrene-like tissue changes resulting in tissue death, body system failure, and frequently death. Those who survive the initial infection, the severe skin and soft tissue damage produced by NF can cause secondary lymphedema to develop. The lymphedema is caused by the disruption of the normal functioning of the lymphatic system in the affected tissues. Lymphedema Does Not Cause NF Lymphedema is the result of damage to the lymphatic system caused by the NF related tissue destruction. Although those with lymphedema are at high risk of developing an infection, cellulitis is the infection most commonly associated with lymphedema. Cellulitis and NF are not the same. One difference is that cellulitis travels through the blood and lymphatic systems and can damage tissues distant from the original wound. Another difference is that NF is a rare infection. Despite the differences, cellulitis is still a dangerous infection and is a medical emergency that requires prompt medical treatment. To learn more read the article titled Cellulitis. Prevention One common factor shared by NF and cellulitis is that they enter the body through even the smallest break in the skin. The skin care precautions you take because of lymphedema also help to protect you from other bacterial infections that invade through a break in the skin. Michael’s Story The onset and treatment of NF is best described as a nightmare. To better understand this, read Michael’s story, which was posted by a Lymph Notes member. For more information visit the National Necrotizing Fasciitis Foundation web site. ........................................................................................... Antibiotics: When They Can and Can't Help What are antibiotics? Antibiotics are strong medicines that can stop some infections and save lives. But antibiotics can cause more harm than good when they aren't used the right way. You can protect yourself and your family by knowing when you should use antibiotics and when you shouldn't. Do antibiotics work against all infections? No. Antibiotics only work against infections caused by bacteria. They don't work against any infections caused by viruses. Viruses cause colds, the flu, and most coughs and sore throats. What is "bacterial resistance"? Usually antibiotics kill bacteria or stop them from growing. However, some bacteria have become resistant to specific antibiotics. This means that the antibiotics don't work against them. Bacteria become resistant more quickly when antibiotics are used too often or are not used correctly. Resistant bacteria sometimes can be treated with different antibiotics to which the bacteria have not yet become resistant. These medicines may have to be given intravenously (through a vein) in a hospital. A few kinds of resistant bacteria are untreatable. What can I do to help myself and my family? Don't expect antibiotics to cure every illness. Don't take antibiotics for viral illnesses like colds or the flu. Often, the best thing you can do is let colds and the flu run their course. Sometimes this can take 2 weeks or more. If your illness gets worse after 2 weeks, talk to your doctor. He or she can also give you advice on what you can do to ease your symptoms while your body fights off the virus. How do I know when I need antibiotics? The answer depends on what is causing your infection. The following are some basic guidelines: Colds and flu. Viruses cause these illnesses. They can't be cured with antibiotics. Cough or bronchitis. Viruses almost always cause these. However, if you have a problem with your lungs or an illness that lasts a long time, bacteria may actually be the cause. Your doctor may decide to try using an antibiotic. Sore throat. Most sore throats are caused by viruses and don't need antibiotics. However, strep throat is caused by bacteria. Usually you'll have a throat swab and a lab test before your doctor will prescribe an antibiotic for strep throat. Ear infections. There are several types of ear infections. Antibiotics are used for some, but not all, ear infections. Sinus infections. Antibiotics are often used to treat sinus infections. However, a runny nose and yellow or green mucus do not necessarily mean you need an antibiotic. Source: http://familydoctor.org/680.xml American Academy of Family Physicians ............................................................................ British Lymphoedema Society Consensus Consensus Document on the Management of Cellulitis in Lymphoedema Cellulitis is an acute spreading inflammation of the skin and subcutaneous tissues characterised by pain, warmth, swelling and erythema. In lymphoedema, attacks are variable in presentation and, because of differences from classical cellulitis, are often called acute inflammatory episodes. Cellulitis will be the term used here (related terms: erysipelas, lymphangitis). Most episodes are believed to be caused by Group A Streptococci. Some episodes are accompanied by severe systemic upset, with high fever or rigors; others are milder, with minimal or no fever. Increased swelling of the affected area may occur. Inflammatory markers (CRP, ESR) may be raised. It is difficult to predict response to treatment. This document makes recommendations about the use of antibiotics for cellulitis in patients with lymphoedema, and advises when admission to hospital is indicated. Prompt treatment is essential to avoid further damage to the affected part which in turn may predispose to repeated attacks. 1. ACUTE ATTACK OF CELLULITIS 1.1 A decision whether hospital admission is indicated should be based on the level of systemic upset: * signs of septicaemia (hypotension, tachycardia, severe pyrexia, confusion, tachypnoea or vomiting) are an absolute indication for admission; * continuing or deteriorating systemic signs, with or without deteriorating local signs, after 48hrs of antibiotic treatment; * un-resolving or deteriorating local signs, with or without systemic signs, despite trials of first and second line antibiotics. 1.2. Management at home 1.2.1. It is essential that the patient is closely monitored, ideally by the GP. To establish a baseline to monitor progress, record: * extent and severity of rash - if possible, mark and date the edge of the erythema (may be difficult in lymphoedema as the rash is often blotchy); * level of systemic upset; * CRP/ESR/white cell count; * Microbiology of any cuts or breaks in the skin before antibiotics are started. 1.2.2. Oral amoxicillin 500mg 8-hourly is the treatment of choice. If there is any evidence of Staph aureus infection e.g. folliculitis, pus formation or crusted dermatitis, then flucloxacillin 500mg 6-hourly should be prescribed in addition. 1.2.3. Patients who are allergic to penicillin should be prescribed clindamycin as in 1.2.4. 1.2.4. If there is no or a poor response (unresolving inflammation or development of systemic symptoms) to oral amoxicillin after 48 hours, then clindamycin 300mg 6-hourly should be substituted as second line oral treatment. 1.2.5. Antibiotics should be continued until all signs of acute inflammation have resolved; this often means taking antibiotics for 1-2 months and the course of antibiotics should be for no less than 14 days from the time a definite clinical response is observed. 1.2.6. Bed rest and elevation of the affected part is essential. Avoid compression garments during the acute attack. 1.2.7. Appropriate analgesia, e.g. paracetamol, as necessary. 1.2.8. When the inflammation is sufficiently reduced, wearing of compression garments and normal levels of exercise may resume. A return to work depends on the patient's occupation, and there being no deterioration when normal levels of exercise are established. 1.3. Management in hospital 1.3.1. Choice of antibiotics in hospital is largely dependent on local rules. Recommended first line treatment is amoxicillin 2g 8-hourly iv plus gentamicin 5mg/kg iv daily; dose to be adjusted according to renal function and assay. Benzylpenicillin 1.2-2.4g 6-hourly may be preferred to the amoxicillin. Convention is to use a combination of benzylpenicillin and flucloxacillin, however, doubts about the role of Staph aureus in cellulitis make this combination less certain. 1.3.2. If there is no or a poor response to this combination after 48 hours, clindamycin 600mg 6-hourly iv should be substituted for both. 1.3.3. Penicillin allergic patients should receive clindamycin as in 1.3.2. 1.3.4. A switch to oral treatment with amoxicillin 500mg 8-hourly, or clindamycin 300mg 6-hourly should not be made before: * Inflammation much resolved; * CRP falling. then continue as in 1.2.5. 1.4. Antibiotics “in case” 1.4.1. The risk of further attacks of cellulitis in lymphoedema is high. It is recommended that patients who have had an attack of cellulitis should carry a two week supply of antibiotics with them particularly when away from home for any length of time, e.g. on holiday. Amoxicillin 500mg tds is recommended or, for those allergic to penicillin, clindamycin 300mg 6-hourly. Antibiotics should be started immediately familiar symptoms of cellulitis start but a medical opinion should be sought as soon as possible. 2. RECURRENT CELLULITIS 2.1. Antibiotic prophylaxis should be offered to patients who have two or more attacks of cellulitis per year. Penicillin V 500mg daily (1g if weight >75kg) should be the first choice. The dose may be reduced to 250mg daily after one year of successful prophylaxis. Prophylaxis may need to be life-long if relapse occurs when antibiotics are discontinued after a two year period of successful prophylaxis. For those allergic to penicillin, erythromycin 250mg daily is recommended; if this is not tolerated then clarithromycin 250mg daily is an alternative. 2.2. There is evidence that decongestive lymphatic therapy reduces the frequency of attacks. Control of the swelling is therefore important. Patients undergoing intensive DLT and known to have suffered cellulitis in the past may benefit from antibiotic cover in case cellulitis is provoked. Oral penicillin V 500mg daily is recommended during the period of the intensive treatment. For those allergic to penicillin, erythromycin is advised (as in 2.1). 2.3. Apart from the swelling other risk factors for recurrent cellulitis including cracked, macerated, inter- digital skin, dermatitis, open wounds including leg ulcers, and weeping lymphangiectasia (leaking lymph blisters on the skin surface) should be treated. Treatment of inter-digital fungus should be with application of terbinafine cream daily for two weeks. 2.4. Those patients in whom first line antibiotic prophylaxis fails may need alternative strategies including trials of prophylactic clindamycin 150mg daily or clarithromycin 250mg daily. Unusual circumstances, e.g. animal bite or lick, preceding an attack, or a failure of infection to respond to above recommendations, should prompt discussions with local microbiologist. Consensus Panel: Professor Peter S. Mortimer, Consultant Dermatologist at the Royal Marsden and St George's Hospitals, London Dr Christopher Cefai, Senior Lecturer in Microbiology, North East Wales Trust Dr Vaughan Keeley, Consultant in Palliative Medicine, Derby Hospitals NHS Foundation Trust Professor John Welsh, Consultant in Palliative Medicine, Beatson Oncology Centre, Greater Glasgow NHS Dr Robert Twycross, Emeritus Clinical Reader in Palliative Medicine, Oxford University Dr Andrew Hughes, Consultant in Palliative Medicine, St Oswald's Hospice, Newcastle Dr Caroline Cooke, Consultant in Palliative Medicine, The Leicestershire Hospice (LOROS) Dr Ellie Bond, Staff Grade Doctor in Palliative Medicine, St Oswald's Hospice, Newcastle Dr Sue Rudd, Staff Grade Doctor in Palliative Medicine, Derby Hospitals NHS Foundation Trust LSN Trustees Published in February 2007 by the British Lymphology Society and the Lymphoedema Support Network. We welcome any comments from users (to be directed to pmortimer@sgul.ac.uk). The document will be revised in October 2007. Reproduction of this information by individual hospital trusts is permitted; however, the following statement must be included in all publications. 'This information is based on a Consensus Document produced by medical experts and facilitated by the Lymphoedema Support Network. The document, originally produced in October 2005, is jointly owned by the British Lymphology Society and the Lymphoedema Support Network' The LSN has produced a new fact sheet based on the Consensus Document, 'Management of Cellulitis in Lymphoedema'. Order forms are available on the LSN website or from the LSN office. Website: www.lymphoedema.org/lsn Tel: 020 7351 0990 |