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Lymphland International Lymphedema Online
| Erysipelas Article Last Updated: Feb 11, 2008 AUTHOR AND EDITOR INFORMATIONS Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References Author: Loretta Davis, MD, Professor, Department of Internal Medicine, Division of Dermatology, Medical College of Georgia Loretta Davis is a member of the following medical societies: American Academy of Dermatology Coauthor(s): John A Cole, BS, Medical College of Georgia; Keith Benbenisty, MD, Consulting Staff, Associates in Dermatology, MDs, PA Editors: Robert A Schwartz, MD, MPH, Professor and Head of Dermatology, Professor of Medicine, Professor of Pediatrics, Professor of Pathology, Professor of Preventive Medicine and Community Health, UMDNJ-New Jersey Medical School; Michael J Wells, MD, Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center; Christen M Mowad, MD, Assistant Professor, Department of Dermatology, Geisinger Medical Center; Glen H Crawford, MD, Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital; Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center Author and Editor Disclosure Synonyms and related keywords: non-necrotizing dermohypodermitis, acute bacterial dermohypodermitis INTRODUCTION Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References Background Erysipelas is a superficial bacterial skin infection that characteristically extends into the cutaneous lymphatics. This disease has been traced back to the Middle Ages where it was referred to as "St Anthony's Fire," named after an Egyptian healer who was known for successfully treating the infection. Historically, this infection occurred on the face and was caused by Streptococcus pyogenes. However, a shift in the distribution and etiology of the disease has occurred, with most erysipelas infections now occurring on the legs and with non–group A streptococci sometimes being identified as the etiologic agents. Pathophysiology Bacterial inoculation into an area of skin trauma is the initial event in developing erysipelas. Thus, local factors, such as venous insufficiency, stasis ulcerations, inflammatory dermatoses, dermatophyte infections, insect bites, and surgical incisions, have been implicated as portals of entry. The source of the bacteria in facial erysipelas is often the host's nasopharynx, and a history of recent streptococcal pharyngitis has been reported in up to one third of cases. Other predisposing factors include diabetes, alcohol abuse,1 HIV infection, nephrotic syndrome, other immunocompromising conditions, and vagrant lifestyle. The infection rapidly invades and spreads through the lymphatic vessels. This can produce overlying skin "streaking" and regional lymph node swelling and tenderness. Immunity does not develop to the inciting organism. Frequency United States Isolated cases are the rule with erysipelas, although epidemics have been reported. The incidence of erysipelas declined throughout the mid-20th century, possibly due to antibiotic development, improved sanitation, and decreased virulence. The change in distribution from the face to the lower extremities is most likely related to an aging population with risk factors such as lymphedema. Approximately 85% of cases occur on the legs rather than the face. International Erysipelas is somewhat more common in European countries. Isolated cases are still the rule, and distribution and etiology remain similar to that in the United States. Mortality/Morbidity The most common complaints during the acute infection include tenderness of the involved area, fever, chills, and swelling. Death as a direct result of erysipelas is exceedingly rare. Predisposed patients often develop local recurrence, and this can lead to disfiguring and disabling healing reactions, such as elephantiasis nostras verrucosa. This chronic warty, edematous condition is caused by lymphatic destruction from repeated infection. Race Erysipelas infections affect all races. Sex Erysipelas has been reported to be more common in females, but occurring at an earlier age in males because of their more aggressive activities. Other studies indicate that predisposing factors, rather than gender, account for any male/female differences in incidence. Age Cases of erysipelas have been reported in all age groups, but it does appear that infants, young children, and elderly patients are the most commonly affected groups. The peak incidence has been reported to be in patients aged 60-80 years, especially in patients who are considered high-risk and immunocompromised or those with lymphatic drainage problems (eg, after mastectomy, pelvic surgery, bypass grafting). CLINICALSection 3 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References History Patients often cannot recall an inciting event, but there may be a history of recent trauma or pharyngitis. Prodromal symptoms, such as malaise, chills, and high fever, often begin before the onset of the skin lesions and usually are present within 48 hours of cutaneous involvement. Pruritus, burning, and tenderness are typical complaints. Physical Erysipelas begins as a small erythematous patch that progresses to a fiery-red, indurated, tense, and shiny plaque. The lesion classically exhibits raised sharply demarcated advancing margins. Local signs of inflammation, such as warmth, edema, and tenderness, are universal. Lymphatic involvement often is manifested by overlying skin streaking and regional lymphadenopathy. More severe infections may exhibit numerous vesicles and bullae along with petechiae and even frank necrosis. With treatment, the lesion often desquamates and can resolve with pigmentary changes that may or may not resolve over time. Causes Streptococci are the primary cause of erysipelas. Most facial infections are attributed to group A streptococci, with an increasing percentage of lower extremity infections being caused by non–group A streptococci. Streptococcal toxins are thought to contribute to the brisk inflammation that is pathognomonic of this infection. No clear proof has emerged that other bacteria cause typical erysipelas, although they clearly coexist with streptococci at sites of inoculation. Recently, atypical forms reportedly have been caused by Streptococcus pneumoniae, Klebsiella pneumoniae, Haemophilus influenzae, Yersinia enterocolitica, and Moraxella species, and they should be considered in cases refractory to standard antibiotic therapy. The role of Staphylococcus aureus, and specifically methicillin-resistant S aureus, remains controversial. No conclusive evidence demonstrates a pathogenic role for staphylococci in typical erysipelas. The infection's predictable response to penicillin, even when S aureus is present, argues against S aureus as an etiologic agent. However, analogous to what occurs in bullous impetigo or staphylococcal scalded skin syndrome, exotoxins from coexisting S aureus may account for the clinical presentation of bullous erysipelas.2 DIFFERENTIALSSection 4 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References Erythema Annulare Centrifugum Other Problems to be Considered Erysipelas can be differentiated from cellulitis by its characteristically raised advancing edges and sharply demarcated borders, reflecting its more superficial nature. Cellulitis has no lymphatic component and exhibits indiscreet margins. WORKUPSection 5 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References Lab Studies In classic erysipelas, no laboratory workup is required for diagnosis or treatment. Routine blood and tissue cultures are not cost-effective because they have an extremely low yield and results have a minimal impact on management. Cultures are perhaps best reserved for very immunosuppressed hosts in whom an atypical etiologic agent might be more likely.3 Bacterial cultures from the portal of entry may be most helpful in persons with atypical clinical presentations. Imaging Studies Imaging studies are not usually indicated and are of low yield. MRI and bone scintigraphy are helpful when early osteoarticular involvement is suspected. In this setting, standard radiographs are typically normal. Histologic Findings The histologic hallmarks of erysipelas are marked dermal edema, vascular dilatation, and streptococcal invasion of lymphatics and tissues. This bacterial invasion results in a dermal inflammatory infiltrate consisting of neutrophils and mononuclear cells. The epidermis is often secondarily involved. Rarely, bacterial invasion of local blood vessels may be seen. TREATMENTSection 6 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References Medical Care Elevation and rest of the affected limb are recommended to reduce local swelling, inflammation, and pain. Saline wet dressings should be applied to ulcerated and necrotic lesions and changed every 2-12 hours, depending on the severity of the infection. Streptococci cause most cases of erysipelas; thus, penicillin has remained first-line therapy.4 Penicillin administered orally or intramuscularly is sufficient for most cases of classic erysipelas and should be given for 10-20 days. A cephalosporin or macrolide, such as erythromycin or azithromycin, may be used if the patient has an allergy to penicillin. Cephalosporins may cross-react with penicillin first-generation cephalosporins and should not be used in patients with a history of severe penicillin allergy, urticarial reactions, or anaphylaxis. Hospitalization for close monitoring and intravenous antibiotics is recommended in severe cases and in infants, elderly patients, and patients who are immunocompromised. Coverage for S aureus is not usually necessary for typical infections, but it should be considered in patients who do not improve with penicillin or who present with atypical forms of erysipelas, including bullous erysipelas. Some authors believe that facial erysipelas should be treated empirically with a penicillinase- resistant antibiotic, such as dicloxacillin or nafcillin, to cover possible S aureus infection, but supporting evidence for this recommendation is lacking.2 Two drugs, roxithromycin and pristinamycin, have been reported to be extremely effective in the treatment of erysipelas. Several studies have demonstrated greater efficacy and fewer adverse effects with these drugs compared with penicillin.5 Currently, the Food and Drug Administration has not approved these drugs in the United States, but they are in use in Europe. Patients with recurrent erysipelas should be educated regarding local antisepsis and general wound care. Predisposing lower extremity skin lesions (eg, tinea pedis, stasis ulcers) should be treated aggressively to prevent superinfection. Use of compression stockings should be encouraged for as long as 1 month in previously healthy patients and for the long-term in patients with preexisting lower extremity edema. Long- term prophylactic antibiotic therapy generally is accepted, but no true guidelines are available. Treatment regimens should be tailored to the patient. One reported regimen is benzathine penicillin at 2.4 MU intramuscularly every 3 weeks for up to 2 years.6 Surgical Care Debridement is necessary only in severe infections with necrosis or gangrene. Consultations Most patients with erysipelas respond very well to conventional antibiotic therapy. However, in atypical infections that are unresponsive to first- and second-line agents, an infectious disease consult may be useful. Activity Patients with acute infections involving the extremities should be encouraged to limit their activity and keep the limb elevated to decrease swelling. MEDICATIONSection 7 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References The objective of pharmacotherapy is to reduce morbidity and to prevent complications. Drug Category: Antibiotics Penicillin is the standard therapy for typical erysipelas, although coverage for S aureus should be considered in the appropriate setting. Drug Name Penicillin (Wycillin, PenVeeK) Description Penicillin G procaine (Wycillin) and penicillin VK (PenVeeK) currently are recommended as first-line agents, indicated for the treatment of moderately severe infections of skin and skin structure. In adults, administer penicillin G procaine by deep IM injection only into upper, outer quadrant of buttock. In infants and small children, the midlateral aspect of the thigh may be a better site for administration. Adult Dose Penicillin G procaine: 0.6-1.2 million U IM bid for 10 d Penicillin VK: 250-500 mg PO qid for 10-14 d Pediatric Dose Penicillin G procaine: <30 kg: 300,000 U/d >30 kg: Administer as in adults Penicillin VK: <12 years: 25-50 mg/kg/d PO divided tid/qid; not to exceed 3 g/d >12 years: Administer as in adults Contraindications Documented hypersensitivity Interactions Increases risk of bleeding when administered concurrently with warfarin; ethacrynic acid, aspirin, indomethacin, and furosemide may compete with penicillin G for renal tubular secretion, increasing penicillin serum concentrations; probenecid can increase effects; coadministration of tetracyclines can decrease effects; may increase methotrexate toxicity; may decrease contraceptive efficacy; may interfere with immunological response to live typhoid vaccine; concurrent administration with aminoglycoside therapy may result in inactivation of aminoglycoside (amikacin appears to possess greatest stability in presence of penicillins; in treatment of severely ill patients requiring both penicillin and aminoglycoside therapy, amikacin is aminoglycoside of choice) Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Never use IV route to administer penicillin G procaine; administer >10 d to eliminate organism and to prevent such complications as endocarditis and rheumatic fever. Drug Name Dicloxacillin (Dycill, Dynapen) Description Treatment of infections caused by penicillinase-producing staphylococci. Penicillinase-resistant penicillin that will cover for S aureus. Adult Dose 125-500 mg PO qid for 10 d Pediatric Dose <40 kg: 12.5 mg/kg/d PO q6h >40 kg: 125 mg PO q6h Contraindications Documented hypersensitivity Interactions Probenecid may increase effect of penicillins; tetracyclines may decrease effect of penicillins with concurrent use Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Renal impairment; cross-sensitivity to other penicillin derivatives; breastfeeding; caution in impaired renal function Drug Name Nafcillin (Unipen) Description Initial therapy for suspected penicillin G-resistant streptococcal or staphylococcal infections. Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants. Because of thrombophlebitis, particularly in elderly patients, administer parenterally only for short term (1-2 d); change to PO as clinically indicated. Adult Dose 1-2 g IV qid for 7 d Infection due to S aureus, penicillinase-producing: 500 mg IV q4h; alternatively, 500 mg IM q4-6h Severe infection: 1000 mg IV or IM q4h Pediatric Dose 0-4 kg: 10 mg/kg IM bid 4-40 kg: 25 mg/kg IM bid; alternatively, 100-200 mg/kg/d IV/IM in 4-6 divided doses Children: 50 mg/kg/d PO divided qid Contraindications Documented hypersensitivity; hypersensitivity to corn or corn products; dextrose solutions may precipitate an allergic reaction Interactions Associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives; concomitant penicillin and aminoglycoside therapy reported to result in inactivation of aminoglycoside both in vivo and in vitro; nafcillin appears to decrease cyclosporine serum concentrations or interfere with cyclosporine assay Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Renal impairment; cross-sensitivity to other penicillin derivatives; breastfeeding; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); adverse reactions include hypokalemia and interstitial nephritis; history of significant allergies or asthma; increased risk for allergic reaction; diarrhea subsequent to nafcillin may be indicative of overgrowth of Clostridium difficile resulting in pseudomembranous colitis Reports of proteinuria associated with high doses of nafcillin indicate this pseudoproteinuria is result of interaction between nafcillin and/or metabolites and quantitative reagents used in TCA (trichloroacetic acid) and sulfosalicylic acid method of urine protein analysis (semiquantitative dipstick technique for estimation of urinary protein [primarily albumin] does not produce this interaction); antibiotics that possess bacterial activity against Salmonella typhi organisms may interfere with immunological response to live typhoid vaccine (allow 24 h or more to elapse between administration of last dose of antibiotic and live typhoid vaccine) Drug Name Erythromycin (E-mycin, E.E.S., Eryc) Description Macrolide used for penicillin-allergic individuals. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections. In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half total daily dose may be taken q12h. For more severe infections, double the dose. Adult Dose 250-500 mg PO qid for 10 d Pediatric Dose 30-50 mg/kg/d (15-25 mg/lb/d) PO divided q6-8h; double dose for severe infection Contraindications Documented hypersensitivity; hepatic impairment Interactions Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals Precautions Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur; hepatotoxicity or skin rash may occur; caution in breastfeeding FOLLOW-UPSection 8 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References Complications The most common complications of erysipelas include abscess, gangrene, and thrombophlebitis. Less common complications (<1%) are acute glomerulonephritis, endocarditis, septicemia, and streptococcal toxic shock syndrome. Rare osteoarticular complications involve joints contiguous with the erysipelas plaques and include bursitis, osteitis, arthritis, and tendinitis.7 Prognosis The prognosis for patients with erysipelas is excellent. Complications of the infection usually are not life threatening, and most cases resolve after antibiotic therapy without sequelae. However, local recurrence has been reported in up to 20% of patients with predisposing conditions. MULTIMEDIASection 9 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References REFERENCESSection 10 of 10 Authors and Editors Introduction Clinical Differentials Workup Treatment Medication Follow-up Multimedia References Jorup-Rönström C. Epidemiological, bacteriological and complicating features of erysipelas. Scand J Infect Dis. 1986;18(6):519-24. [Medline]. Krasagakis K, Samonis G, Maniatakis P, Georgala S, Tosca A. Bullous erysipelas: clinical presentation, staphylococcal involvement and methicillin resistance. Dermatology. 2006;212(1):31-5. [Medline]. Leppard BJ, Seal DV, Colman G, Hallas G. The value of bacteriology and serology in the diagnosis of cellulitis and erysipelas. Br J Dermatol. May 1985;112(5):559-67. [Medline]. Bishara J, Golan-Cohen A, Robenshtok E, Leibovici L, Pitlik S. Antibiotic use in patients with erysipelas: a retrospective study. Isr Med Assoc J. Oct 2001;3(10):722-4. [Medline]. Bernard P, Plantin P, Roger H, Sassolas B, Villaret E, Legrain V, et al. Roxithromycin versus penicillin in the treatment of erysipelas in adults: a comparative study. Br J Dermatol. Aug 1992;127(2):155-9. [Medline]. Sjöblom AC, Eriksson B, Jorup-Rönström C, Karkkonen K, Lindqvist M. Antibiotic prophylaxis in recurrent erysipelas. Infection. Nov-Dec 1993;21(6):390-3. [Medline]. Coste N, Perceau G, Léone J, Young P, Carsuzaa F, Bernardeau K, et al. Osteoarticular complications of erysipelas. J Am Acad Dermatol. Feb 2004;50(2):203-9. [Medline]. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. Jan 25 1996;334(4): 240-5. [Medline]. Bonnetblanc JM, Bédane C. Erysipelas: recognition and management. Am J Clin Dermatol. 2003;4(3): 157-63. [Medline]. Bratton RL, Nesse RE. St. Anthony's Fire: diagnosis and management of erysipelas. Am Fam Physician. Feb 1 1995;51(2):401-4. [Medline]. Chartier C, Grosshans E. Erysipelas. Int J Dermatol. Sep 1990;29(7):459-67. [Medline]. Chartier C, Grosshans E. Erysipelas: an update. Int J Dermatol. Nov 1996;35(11):779-81. [Medline]. Elston DM. Epidemiology and prevention of skin and soft tissue infections. Cutis. May 2004;73(5 Suppl):3- 7. [Medline]. Grosshans EM. The red face: erysipelas. Clin Dermatol. Apr-Jun 1993;11(2):307-13. [Medline]. Hammar H, Wanger L. Erysipelas and necrotizing fasciitis. Br J Dermatol. Apr 1977;96(4):409-19. [Medline]. Ronnen M, Suster S, Schewach-Millet M, Modan M. Erysipelas. Changing faces. Int J Dermatol. Apr 1985;24(3):169-72. [Medline]. Török L. Uncommon manifestations of erysipelas. Clin Dermatol. Sep-Oct 2005;23(5):515-8. [Medline]. Zeglaoui F, Dziri C, Mokhtar I, Ezzine N, Kharfi M, Zghal M, et al. Intramuscular bipenicillin vs. intravenous penicillin in the treatment of erysipelas in adults: randomized controlled study. J Eur Acad Dermatol Venereol. Jul 2004;18(4):426-8. [Medline]. Erysipelas excerpt Article Last Updated: Feb 11, 2008 ----------------------------------------------------------------------------------------------------------- Pain syndromes Q. I have just been diagnosed with shingles (very painful) and they are spreading toward my lymphedema side. I have been managing my LE for two years, but I m frightened that this could aggravate the LE. I am treating with w/Famvir and patience. The clinic analyzing the shingles did not seem knowledgeable about a possible impact on LE. Can you help me with this? A. I have treated several patients who developed shingles either before or after CLT treatment, often on the trunk on the lymphedematous side. In some patients, the inflammation did worsen the swelling temporarily, but with a bit of extra care, this swelling was resolved. Those who were maintaining good reduction prior to the shingles found that they were able to continue this, or regain their reduction fairly quickly as the shingles resolved. Prevention of secondary infection is the most important thing for you now. I would recommend applying antibiotic ointment to any lesions that are open and oozing to help prevent this. Monitor your skin very carefully. If there is any sign of even a local infection, consult with your physician about starting systemic antibiotics to avoid a local infection from progressing rapidly into a more serious systemic infection. Q. I recently ran across an article that mentioned the medication "Daflon" in the treatment of lymphedema. I am always searching for new information and have never heard of this. Can you tell me a little about this medication and how it is used? A. Daflon has been used for varicose veins and other conditions, and is available in many countries. It works much the same way as the benzopyrones, i.e. by enhancing the macrophage activity and increasing the numbers (this has been well established in experimental models). Daflon has been successfully tested in clinical trials for the treatment of lymph-edema, but optimal dosages are still undecided. At this point in the trials, the higher dose has been more successful. (Pecking [France]; Ciucci [Argentina]) We think that probably the dose should be at least 2gm per day, but 900mg taken cautiously should help. I suggest you contact Servier Laboratories, the manufacturer, directly for further info. Director of Research, Institut de Recherches Internationales Servier (I.R.I.S.) 6, Place des Pleiades - 92415 Courbevoie Cedex FRANCE. Tel: (33 1) 46 41 60 00. email: lerond@servier.fr. Daflon Shingles Menstration and LE Q: I am 40 years old and have secondary lymphedema of both legs from injuries sustained in a car accident in 1993. I notice that when it is time for my monthly period, no matter what I do or how much I use my lymphatic pump (Wright Linear Pump, which usually helps a great deal), I swell up so extremely the fluid even moves into the pelvis and abdomen, and my right leg is in excruciating pain. After my period the swelling in my abdomen subsides. FYI: My right leg developed lymphedema from cellulitis after the accident (from glass puncture wounds) and there is a constant nagging ache. My left leg does not hurt. What do you know of the connection between the two? A: As you know, most women accumulate fluid before and during their monthly period. But patients with lymphedema particularly have problems and often feel extremely bloated during this time. Clearly, the affected limb, and often the rest of the body, feels extremely uncomfortable, and the compression garment becomes too tight. My advice is: lower your salt intake even more during this time; drink lots of water to dilute and improve the circulation and increase urination, and maybe wear a larger garment. Patients who have had severe cellulitis often end up with persistant subclinical inflammations resulting in ongoing pain/discomfort. You might try prophylactic antibiotics for a period of 3 months ( Pen VK 250mg one tbl. day). How to get your doctor to listen about le Q: How do you get your doctor to listen to your concerns about lymphedema, especially if s/he doesn't think it is a serious problem? A: Contact the NLN office and request a copy of the Consensus document: The Diagnosis and Treatment of Peripheral Lymphedema written by the Executive Committee of the International Society of Lymphology (Lymphology 28[1995] 113-117). Bring this to your doctor's attention and make sure he or she reads it. It's an excellent first step to educating your physician and other health care providers and, hopefully, getting the care you need. Compression garments without therapy first Q: If you can't afford Manual Lymph Drainage, is it safe to buy and use a CircAid or Reid Sleeve? Do you have to use both of them or, if you can only afford one, which one should you use? A: You can use both of them or only one. The Reid sleeve can be used as a maintenance garment after the limb has been decongested and usually is worn throughout the night instead of bandaging. The CIRCAID is used during the day and worn over the thigh-high compression stocking (the below -the-knee CircAid). This also is available in a full-length style which is worn during the night to replace bandaging. Both the Reid sleeve and the CircAid devices are extremely effective and many patients use both. If you can only afford one, consider purchasing the one that will bring the most simplicity to your daily self-care program. Indeed, Manual Lymph Drainage can be expensive or often insurance companies will not reimburse for this treatment. I highly recommend investing in the Self-Care videotape designed by JoAnn Rovig, LMT for patients who have no therapist in their area or who cannot afford treatment. Many patients and clinics are using this video and the feedback has been excellent. The video instructs viewers in the educational and self-management aspects of lymphedema. (The video is available through the NLN, please consult the Reprints List.). -------------------- Lymphedema and pain Common Pain Syndromes in Lymphedema Infection Cellulitis Lymphangitis Myofascial Pain Syndromes Frozen Shoulder Neuropathic Pain Syndromes Postmastectomy Pain Syndrome Phantom Breast Pain Brachial Plexopathies Peripheral Neuropathy Chemotherapy Entrapment Neuropathies Carpal Tunnel Syndrome Ulnar Entrapment Vascular Compromise Deep Vein Thrombosis Arthritis Degenerative Inflammatory Table 2. Adjuvant analgesic classes useful in the treatment of nerve pain Tricyclic Antidepressants Anticonvulsants Oral local anesthetics Antispasticity agents Neuropleptics Capscacin Dr. Brennan is Chief of Rehabilitation Medicine at the United States-based Bridgeport Hospital and works for the Ahlbin Centers For Rehabilitation Medicine. Q: I have had my lymphedema in my right arm for five years, and recently it started to hurt badly. My doctor is no help, and I haven't seen this mentioned in your newsletter. A: Thank you for this important question. There are an increased number of patients who contact us regarding pain. Some have become quite upset since we advise them that usually lymphedema does not hurt, except, of course, the discomfort of psychological pain. But any time there is pain it is important to rule out recurrent disease, infections, nerve related pain (brachial plexus) or other. Pain can aggravate and worsen the swelling, and it is important to discontinue therapy until one knows what is causing these symptoms. Some patients have continuous pain and we do not know why. Once complications have been ruled out, starting Manual Lymphatic Drainage and bandaging to keep the limb as small as possible is recommended; decongesting the limb brings many benefits all around. Q: Is it true that stress aggravates lymphedema? A: Stress is the plague of our modern, fast-track world. The state of being "stressed out" is an all too common complaint of adults and, more recently, children and teens. Too much to do in not enough time, the increasing demands of 10- and 12-hour workdays while still trying to maintain a balanced life, handling the discomfort of being a child that does not "fit in" - these are just a few of the many causes of stress. A number of studies have been done highlighting the negative effects of stress on the major organ systems - blood pressure, heart rate, blood vessel dilation/constriction, increased sympathetic nervous system stimulation triggering the "fight or flight" response, changes in respiration, muscle tone, etc. All of the above directly or indirectly influence the function of the lymphatic system. Stress and le Q: Is it true that those of us with lymphedema who need teeth cleaning are at a higher risk of developing an infection in our limb(s)? Should we take antibiotics beforehand? A: This question has yet to be answered by any clinical studies, however, it is common knowledge that the mouth is an ideal environment for bacteria. Even during such routine work as teeth cleaning, the gums often do bleed and bacteria can then enter the blood stream and, subsequently, the lymphatics. This can adversely affect a weakened lymphatic system which may be more prone to developing an infection. For those with sensitive gums, a very soft toothbrush is advised and if your gums bleed after brushing, it may be helpful to use an anti-bacterial mouth rinse on a regular basis. Consult with your dentist. Dental and LE These are all old exerpts from the National Lymphedema Network questions and answers and the ELymphNotes.com question and answers websites, many of the original pages do not exist anymore, we have chose to keep these routinely asked questions up to help people, we are not medical professionals and are only sharing this information, it is not meant to replace the medical advice of your doctor. Page was put up 1/07, by the Lymphland Editorial Team. -------------------------------------------------------------------------------------------------------- Lymph Node Transfers I have personally checked with Dr. Massey's office and obtained confirmation that she does perform inguinal lymph node transfers to treat lower limb lymphedema patients upon careful examination. Her web site makes more references to upper limb lymphedema. If you intend to contact Dr. Massey, I would appreciate that you mention where you got her contact information. Good health to you all, Pierre MERCIER, BSc MA, Lymphedema Therapist, Gatineau, Quebec, Canada PS The original information I received contained a couple of medical articles on this topic in PDF format that I would be happy to share. _________________________________________________________________________________ _________________ LYMPHEDEMA PATIENTS Reverse The Signs And Symptoms Of Lymphedema We are proud to announce the creation of a new ground-breaking surgical procedure to improve the symptoms associated with lymphedema. Dr. Marga F. Massey is a board-certified plastic surgeon with specialty training in microsurgery. Beginning January 2009 at Chicago 's Advocate Trinity Hospital , Dr. Massey began offering a new innovation in microsurgery leading to an improved quality of life for lymphedema patients the world over. If you are experiencing lymphedema, in any of it's various forms, you may be a candidate for vascularized lymph node transplantation, a simple procedure that can reverse the symptoms associated with lymphedema and improve your overall quality of life. We are very excited about being able to offer this innovative, life-changing procedure in Chicago , Illinois . To learn more about Dr. Massey and the lymphedema microsurgery, please visit us online at www.drmarga. com . If you would like to schedule a consultation in our office, please call us at: 1-312-725-4322 Vascularized lymph node transplantation is a safe procedure permitting good long-term results and the disappearance, or significant improvement, of lymphedema symptoms most in patients who undergo the procedure ******Keep in mind the above is an experimental treatment and is NOT endorsed by lymphland. *It is the opinion of myself, Tina, the practice is not safe due to the debate of whether or not there really is a secondary lymphedema. Studies are emerging that suggest that all lymphedema might be primary and caused by secondary triggers. In that case, surgery to remove nodes from one area to put in another could cause lymphedema to settle in the area of removal. ---------------------------------------------------------------------------------------------------- There are some options for genital edema, though none are easy. For females, you can get a long line panty shaper (which was formerly called a girdle) and then sew another crotch within the crotch to form a pocket. In this you can place either foam, or a heavy kotex (maternity) which will provide pressure against the labia. Not terribly comfortable, but can be effective. There is also genital pads from Solaris (male and female) which are then held in place by a long leg panty or underarmor for men. The male genitalia can be bandaged and then supported with a scrotal support. The scrotum and penis will reduce, it is more of a challenge for female genital edema. Hope this helps Renee Romero RN, CLT-LANA of Bandages Plus ---------------------------------------------------- |