What are the treatment options for lymphedema?

Treatment of Lymphedema

Refer all patients with clinical symptoms or swelling suggestive of lymphedema to a specialized lymphedema therapist (physical therapist, occupational therapist, or certified lymphedema specialist) for Complete Decongestive Therapy (CDT), which consists of manual lymphatic drainage, compression therapy, exercise, and skin care. 1, 2, 3

First-Line Treatment: Complete Decongestive Therapy

CDT is the gold standard for lymphedema management and consists of four essential components that must be used together 2, 4, 5:

Phase I: Intensive Treatment (Clinical Setting)

• Manual lymphatic drainage (MLD): A specialized massage technique that stimulates lymph flow by achieving effective pressure gradients and reducing lymphatic network resistance 2, 6
• Compression bandaging: Multi-layer, short-stretch (inelastic) bandaging is the most critical component—lymphedema can be improved with bandages alone, but sustained improvement cannot occur without compression 2, 5
• Decongestive exercises: Performed while wearing compression to enhance lymphatic flow 2, 6
• Meticulous skin care: Diabetic-type skin care to prevent cellulitis and other infections 7, 5

For patients with sensitivity to bandaging, prioritize MLD as the primary treatment modality. 2, 3

Phase II: Maintenance (Home Management)

• Elastic compression garments: Stockings or sleeves with minimum pressure of 20-30 mmHg for mild cases, 30-40 mmHg for more severe disease 2
• Continued MLD (can be self-administered after proper training) 5
• Regular exercise: 150 minutes of moderate-intensity activity weekly to maintain lymphatic flow 2
• Ongoing skin care and self-management education 4, 3

Critical Risk Reduction Strategies

Counsel all patients on weight loss if overweight or obese—this is a major modifiable risk factor for both development and progression of lymphedema. 1, 2, 3 Refer to a registered dietitian for structured weight management counseling 3.

Treat all infections promptly with systemic antibiotics, as cellulitis and lymphangitis are common complications that significantly worsen lymphedema. 2, 5 The risk of recurrent erysipelas is high, and streptococcal infections always require systemic antibiotic therapy 5.

Adjunctive Treatment Options

• Low-level laser therapy: Can reduce arm volume and improve quality of life (Grade C evidence) 2
• Supervised progressive resistance training: Safe and potentially beneficial—contrary to historical advice, complete avoidance of physical activity is not necessary 2, 3
• Intermittent pneumatic compression (IPC): May support home management, particularly with advanced programmable devices that provide truncal clearance 6, 8

When Conservative Treatment Fails

Consider referral for microsurgical interventions (lymphovenous anastomoses or vascularized lymph node transfer) when conservative treatment is insufficient. 2, 3 Microsurgery has shown effectiveness for refractory cases, though it should only be performed after conservative therapy has been exhausted 7, 9.

Excisional surgery (debulking procedures) should be reserved for severe cases affecting function, particularly genital lymphedema or facial swelling compromising vision 7. Circumferential suction-assisted lipectomy has shown promise for long-term symptom relief in selected candidates 9.

Critical Pitfalls to Avoid

• Never use diuretics for pure lymphedema—they are physiologically unsound and ineffective, though may have limited use in mixed edema or palliative cancer settings 4, 7
• Do not delay treatment—early intervention is critical as lymphedema may be reversible or more effectively managed with early physiotherapy 3
• Do not fail to differentiate lymphedema from other causes of swelling (lipedema, venous insufficiency, systemic causes)—this leads to inappropriate treatment 4
• Ensure truncal clearance during MLD or IPC—this is key to facilitating drainage from affected limbs 6

Treatment Algorithm Summary

1. Immediate referral to certified lymphedema therapist upon clinical suspicion 1, 3
2. Phase I intensive CDT in clinical setting with all four components 2, 5
3. Transition to Phase II home maintenance with compression garments and self-management 5, 6
4. Address modifiable risk factors: weight loss, infection prevention 1, 2
5. Consider microsurgery only if conservative treatment fails after adequate trial 2, 3

The strength of evidence for CDT is high with strong recommendations from the National Comprehensive Cancer Network, American Cancer Society, and American Society of Clinical Oncology 1, 2, 4.