|
| HYPERKERITOSIS In long standing lymphedemas hyperkeritosis can be a problem. This is an overabundant skin thickening with callous formation and possibly wart-like papillomas. It is gray-brown in color and can occur anywhere on the involved area. This is not often seen in upper extremity involvement. Sometimes hyperkeritosis can be mistaken for dried lymph fluid. Hyperkeritosis is a skin change, a scarring, and should never be removed through debridement. Surgical excision is the only treatment, however effective skin care treatment can substantially reduce the severity. FUNGAL INFECTIONS Fungal infections occur frequently in lower extremity lymphedema patients. The stagnant protein rich fluid is a breeding ground for bacteria and feet enclosed in a dark, moist environment are prime targets for infections. Fungal infections manifest themselves through itching between the toes, small blisters, a gray or whitish film on the skin, and foul odor. Sometimes the skin peels off between the toes. Initially only slight scale may be noted but soon it spreads and nail changes can take place. It can be a problem in only one foot or it can be bilateral. Patients with foot fungus need to be careful not to contaminate other household members. The infected patient can shed tiny fragments of skin and fungus. Similar sources of infection exist in discarded bandages or clothes on any surface. The tub or shower should be cleaned thoroughly immediately after use. Patients should not go barefoot in the bathroom but lay a towel down on the floor. That towel needs to be removed and placed in the wash immediately after use. All towels and washcloths should be used only once before washing. Going barefoot generally is not recommended unless the patient has been instructed to air feet at regular intervals. These patients should not go barefoot in the therapy clinic. Make sure you place a towel on the floor for the patient to step onto after removing shoes. Do not have the patient drop socks or stockings onto the floor. They should be placed inside the patient’s shoes. In the beginning stages of foot fungus, over the counter foot fungal medications can be used. Sometimes a prescription drug is required. Patients with repeated problems of foot fungus need to be followed by a physician. The therapist may chose to include treating the foot fungus as a part of the therapy session. Gloves should be worn.LYMPHATIC CYSTS These are abnormally widened initial lymph vessel visible as tiny vesicles or blisters. When they burst there is danger of infection. These need to be monitored daily. During manual lymph drainage be careful of over-pulling the skin around these areas. There should be no stimulation directly over the area itself. With increasing decongestion of the lymphedemetous area, the lymphatic cysts usually dry up. The skin needs to be kept supple and moist. Lymphedema is a very drying condition. Cracks in the skin, particularly on the feet and around the toe and fingernails, need to be avoided. A good low pH lotion or cream is recommended. Lotions or creams that have fragrances, dyes or lanolin should not be considered. There are many products on the market that advertise "low pH" or "pH balanced" and these are preferred. The best time to apply moisturizer is after bathing. It is not recommended it be applied just prior to donning medical compression garments. Lotions/creams can get "caught" up in the garment fabric. If the patient doesn’t wash the garment daily, this can hasten the deterioration of the garment fabric. Some patients can develop itching or a rash if applied prior to bandaging, particularly in the hot summer weather. Maintaining a good fluid intake will assist with skin moisturization. Sometimes patients mistakenly think if they limit the fluid intake, the swelling in the involved limb will be reduced. Good skin integrity can only be maintained if oral fluids are adequate |
| Hyperkeratosis and Papillomatosis By Jenny Veitch, Lymphoedema Specialist Hyperkeratosis Papillomatosis What are hyperkeratosis and papillomatosis? These are changes which can take place within the skin and present as thickening and solidness (described as fibrosis*) of the tissues. The cause of these characteristic changes is the result of untreated lymphoedema and are generally found on lower limbs. How can they be recognised? Hyperkeratosis is a warty scaly change in the skin due to an increased production of keratin, a surface protein. Papillomatosis is a cobblestone change in the skin surface due to dilated surface lymphatic vessels or focal accumulations of lymph; they are non-compressible due to thickening and fibrosis of surrounding tissues. Warty hyperkeratosis and papillomatosis often coexist in which case the skin resembles elephant skin (known as elephantiasis). How can they be prevented? As already stated, these changes generally appear as a result of oedema being untreated. The fitting of good quality compression hosiery and meticulous daily skin care, including the use of moisturising cream, should help to prevent changes occurring within the skin and tissues. How can these changes be treated? It is important to moisturise the affected area twice daily with 50% white soft paraffin and 50% liquid paraffin mixed, until the skin improves. In more severe cases, salicylic acid 5% in an ointment base may be used, this will help to lift the scales from the skin surface. This must be discussed with the health care professional responsible for your care. When the skin condition has improved, daily application of aqueous cream can be applied at night in order to keep the skin well hydrated and supple. Appropriate class and size of compression hosiery must be worn daily to maintain the improved skin condition. If the limb is very swollen and distorted in shape it will be essential to receive an intensive course of treatment known as decongestive lymphatic therapy (DLT) from a qualified lymphoedema specialist. NB * Fibrosis is an increase in the thickness and amount of collagen in the skin. It conveys a harder consistency to the tissues concerned. |
| Lymphorrhoea By LSN Trustee and Nursing Advisor, Denise Hardy Lymphorrhoea is the leakage, or weeping, of lymph fluid through the skin surface. Large beads of fluid appear on the skin and trickle from the affected areas. Causes of Lymphorrhoea May be the result of lacerations, abrasions, or trauma of the altered dry skin of longstanding oedema e.g. graze/cut It may result from the rupture (bursting) of lymphangiomas (described more fully below) It may also occur in a sudden or acute oedema (swelling) where the shiny, taut skin has stretched so rapidly that it splits, forming a leak. Lymphorrhoea - the problems it causes The skin feels very cold, wet and uncomfortable The fluid can soak through dressings which may need changing many times a day to cope with the large amounts of leakage The fluid can collect in shoes/slippers clothing and bed linen can become soaked and require frequent changes Lymphorroea will increase the risk of cellulitis - the break in the skin acts as an entry for bacteria. Infection will cause further problems (pain/inflammation/flu-like symptoms and increased amounts of fluid leakage) If left to leak and dressings are not regularly changed the lymph (being an excellent culture medium) may grow bacteria causing odour and discolouration Lymphorrhoea may cause social difficulties and embarassement. Lymphorrhoea not uncommonly affects the genital area and may be difficult to distinguish from urinary incontinence. Treatment of Lymphorrhoea In order to stop the fluid leaking, a series of steps are essential. Your Lymphoedema nurse/therapist or other nurse involved in your care should be able to help you with these steps following a full assessment of the cause of the leakage: The area around the 'leak' needs to be cleaned carefully to ensure the risk of infection is reduced. An emollient (moisturising cream/lotion) should be applied to the skin to improve the condition and protect it (by acting as a barrier) against further skin breakdown. A non-adherent (non sticky), absorbent, (e.g. Allevyn/Cutinova/lyofoam) sterile dressing should be applied to the leaking area to prevent further trauma to the skin - and to absorb the leakage. Pressure should be applied. For example a limb should be supported with appropriate bandaging e.g. Multi Layer Lymphoedema Bandaging (MLLB) with short stretch compression bandages. This normally stops the flow of leakage within 24-48 hours. Bandages may have to be replaced frequently during this period of time to remove wet bandages/ dressings and to prevent further skin breakdown. MLLB should continue until the skin condition has improved enough to wear your stockings/sleeve again. At rest, the affected limb should be elevated to reduce the effects of gravity. Once the leakage has stopped, and the skin condition has improved, your usual compression garment should once again be applied. The garment will keep the swelling to a minimum and prevent any further 'leaks' appearing. Lymphangiomas Lymphangiomas are often referred to as 'lymph blisters'. They consist of enlarged, or bulging lymphatic vessels just under the surface of the skin, which give the appearance of a blister. Lymphangiomas can occur as a result of damage to the deep lymphatic vessels e.g. following radiotherapy, or surgery and they generally contain clear lymph fluid (though sometimes it can be blood stained). If Lymphangiomas burst, they result in wetness around the area or even profuse leakage which is a risk of potential infection. Treatment involves strict skin hygiene and the usual lymphoedema cornerstones of treatment - especially compression. If left untreated, the lymph blisters may become harder and firmer and begin to look like firm skin nodules. Lymphangiomas are not cancerous. |
| LYMPHLAND |
