What are the management options for lymphedema?

Management Options for Lymphedema

Complete decongestive therapy (CDT) is the most effective treatment approach for lymphedema, consisting of manual lymphatic drainage, compression therapy, skin care, and exercise. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Diagnostic criteria:

  • Unilateral presentation (typically in secondary lymphedema)
  • Positive Stemmer sign
  • Circumferential measurement showing ≥2 cm increase compared to unaffected limb
  • Volume difference >200 mL or >10% interlimb difference 1

• Gold standard diagnostic test: Lymphoscintigraphy 1

• Additional diagnostic tools:

  • Ultrasound
  • MRI
  • CT
  • Bioimpedance Analysis (BIA) with L-Dex score >7.1 1

Treatment Approach

Phase 1: Intensive Treatment

The initial phase focuses on volume reduction and is typically conducted by a certified lymphedema therapist:

1. Compression therapy - The most critical component 2

   • Multilayer inelastic bandaging
   • Applied with gradient pressure (higher distally, lower proximally)

2. Manual lymphatic drainage (MLD)

   • Specialized massage technique to stimulate lymphatic flow
   • Particularly beneficial for patients with sensitivity to bandaging 1
   • Note: Recent evidence suggests compression bandaging alone may be equally effective as CDT with MLD in more severe postmastectomy lymphedema 3

3. Decongestive exercises

   • Gentle, progressive physical activity to stimulate lymphatic flow
   • For upper extremity lymphedema: incorporate scapular and rotator cuff strengthening 1

4. Meticulous skin care

   • Prevents infections that can worsen lymphedema
   • Daily cleansing and moisturizing 1

Phase 2: Maintenance Phase

After initial volume reduction, focus shifts to maintaining results:

1. Compression garments

   • Custom-fitted elastic stockings or sleeves
   • Worn during daytime activities 2, 4

2. Continued self-management

   • Home-based MLD techniques
   • Regular exercise program
   • Ongoing skin care 5

3. Elevation of affected areas

   • Promotes gravity drainage of edema 1

Adjunctive Treatments

• Intermittent pneumatic compression (IPC)

  • Mechanical device that applies sequential pressure
  • Particularly useful for home management 4

• Resistance training

  • Can be beneficial but requires special precautions
  • Always use compression garments during exercise 1

Complications Management

• Infection prevention and treatment

  • Prompt antibiotic treatment if infection is suspected
  • First-line options: penicillinase-resistant penicillin or first-generation cephalosporin 1
  • Consider prophylactic antibiotics for recurrent infections 1

• Pain management

  • Acetaminophen, NSAIDs for general pain
  • Duloxetine for neuropathic pain components
  • Acupuncture may provide additional benefit 1

Key Clinical Considerations

• Lymphedema treatment is typically lifelong and symptomatic rather than curative 2
• Referral to a specialized lymphedema therapist is essential for optimal management 1, 5
• Regular monitoring of limb volume and symptoms is crucial for effective management 1
• Patient education about self-management techniques and infection risk is vital for long-term success 1

Treatment Efficacy

CDT has been shown to reduce edema volume by approximately 47% during the intensive phase, with improvements maintained during proper maintenance therapy 3. The effectiveness of treatment should be evaluated by objective methods, such as measuring limb perimeters or volumes 2.