What are the treatment options for lymphedema?

Lymphedema Treatment Options

Manual lymphatic drainage (MLD) and compression bandaging are the primary recommended treatments for lymphedema, with either therapy being considered effective, and MLD particularly recommended for patients with sensitivity to bandaging. 1

Diagnosis and Assessment

Before initiating treatment, proper assessment is essential:

• Use standardized assessment tools such as:
  • NCI CTCAE v.4.03
  • Tape measurements (circumferential measurement with ≥2 cm increase compared to unaffected limb)
  • Sonography
  • External photographs 1
  • Lymphoscintigraphy (gold standard diagnostic tool) 2
  • Bioimpedance Analysis with L-Dex score >7.1 or >10 above baseline 2

First-Line Treatment: Complete Decongestive Therapy (CDT)

Complete decongestive therapy is the mainstay of lymphedema management and consists of four essential components:

1. Manual Lymphatic Drainage (MLD)

   • Specialized massage technique that stimulates lymphatic flow
   • Particularly beneficial for patients with sensitivity to compression bandaging 1
   • Should be performed by trained rehabilitation specialists 1

2. Compression Therapy

   • Short-stretch compression bandaging during initial treatment phase
   • Compression garments (sleeves/stockings) for maintenance phase
   • Most critical component of lymphedema treatment 3

3. Meticulous Skin Care

   • Gentle cleansing and moisturizing to prevent infections
   • Prompt treatment of any skin breaks or infections 2

4. Decongestive Exercises

   • Gentle, progressive physical activity to stimulate lymphatic flow
   • Should be performed while wearing compression garments 2

Treatment Phases

CDT is typically administered in two phases:

1. Phase I (Initial/Attack Phase)

   • Intensive treatment in clinical setting
   • Daily 60-90 minute sessions, 5 days/week for 2-4 weeks 4
   • Includes all four components of CDT
   • Goal: maximum volume reduction

2. Phase II (Maintenance Phase)

   • Self-management at home
   • Compression garments during day
   • Self-administered MLD or use of pneumatic compression devices
   • Regular exercise and skin care 5

Adjunctive Treatments

• Intermittent Pneumatic Compression (IPC)

  • Mechanical device that applies sequential pressure
  • Particularly useful for home management
  • Should include truncal clearance before limb compression 5

• Elevation of Affected Limb

  • Promotes gravity drainage of edema
  • Should be incorporated into daily routine 2

• Dietary Counseling

  • Weight management is important as obesity is a risk factor 2

Monitoring and Follow-up

• Regular reassessment of limb volume/circumference
• Monitoring for complications (infections, decreased mobility)
• Adjusting compression garments as needed

Complications and Management

• Infections

  • Prompt antibiotic treatment for erysipelas (always streptococcal origin) 3
  • Consider prophylactic antibiotics for recurrent infections 2

• Pain Management

  • Acetaminophen, NSAIDs for mild pain
  • Specialized referral for severe or neuropathic pain 2

• Decreased Mobility

  • Physical therapy to maintain joint function
  • Specialized exercises for affected limb 2

Treatment Efficacy

Research shows that CDT is effective in reducing lymphedema volume and improving quality of life:

• Studies demonstrate median girth reduction of 1.5 cm and volume reduction of 138 mL after initial treatment 4
• Long-term follow-up shows stabilization at about 1 cm and 100 mL below baseline 4
• Pain reduction correlates significantly with decreasing limb girth 4

Surgical Options

For patients who don't respond to conservative therapy, surgical options may be considered:

• Microsurgical lymphatic anastomoses
• Circumferential suction-assisted lipectomy (most promising for long-term relief) 6

Patient Education

Patient education is crucial for successful management:

• Self-monitoring techniques
• Proper use of compression garments
• Skin care practices
• Infection prevention strategies
• Importance of compliance with home maintenance program 2

The evidence clearly supports complete decongestive therapy as the standard of care for lymphedema, with manual lymphatic drainage and compression therapy being the cornerstone treatments that significantly improve morbidity, mortality, and quality of life outcomes.