What are the treatment options for drainage from legs due to lymphedema?

Treatment of Leg Lymphedema with Drainage

The primary treatment for leg lymphedema with drainage is complex decongestive therapy (CDT), which must include manual lymphatic drainage, compression bandaging (20-30 mmHg minimum, 30-40 mmHg for severe disease), exercise, and meticulous skin care, with immediate referral to a certified lymphedema specialist being essential for optimal outcomes. 1, 2

Immediate Management Algorithm

Step 1: Assess for Active Infection

• If drainage is accompanied by erythema, warmth, or systemic symptoms, initiate antibiotics immediately with penicillinase-resistant penicillin, first-generation cephalosporin, or clindamycin/vancomycin for penicillin-allergic patients 3
• A 5-day antibiotic course is as effective as 10 days for uncomplicated cellulitis 3
• Elevate the affected limb to promote gravity drainage of edema and inflammatory substances 3

Step 2: Refer to Specialized Lymphedema Therapist

• Refer immediately to a physical therapist with lymphedema certification, occupational therapist with lymphedema training, or certified lymphedema specialist 1, 2
• Early intervention is critical as lymphedema may be reversible or more effectively managed with early physiotherapy 2
• Delayed treatment leads to progression and increased complications 1, 2

Core Treatment Components (Complex Decongestive Therapy)

Manual Lymphatic Drainage (MLD)

• This specialized massage technique stimulates lymph flow and is recommended as first-line treatment (Grade C evidence) 1
• MLD is particularly beneficial for patients with sensitivity to bandaging due to allergies or discomfort 1, 2
• Must be performed by appropriately trained specialists 2

Compression Therapy

• Compression is the most important treatment component - lymphedema cannot achieve sustained improvement without compression 4
• Use multilayer inelastic bandaging during the initial attack phase to reduce volume 4
• Minimum pressure of 20-30 mmHg is required, with 30-40 mmHg advised for more severe disease 1
• Transition to elastic compression stockings or sleeves during the maintenance phase 4
• High-pressure sequential external pneumatic compression (90-100 torr) has shown long-term efficacy with 90% of patients maintaining reduced limb girth 5

Skin Care

• Keep skin well-hydrated to prevent dryness and cracking, which serve as portals for bacterial entry 3
• Treat interdigital maceration and fungal infections to prevent cellulitis 3
• Keep nails short to minimize damage from scratching 3
• Diabetic-type skin care is essential to control recurrent inflammatory episodes 6

Exercise

• Supervised progressive resistance training is safe and may improve lymphedema symptoms 1, 2
• Aim for 150 minutes of moderate intensity activity weekly to maintain lymphatic flow 1
• Use compression garments during exercise if lymphedema is present 2
• Contrary to historical advice, complete avoidance of physical activity is not necessary 2

Three-Phase Treatment Approach

Phase 1: Attack/Initial Treatment

• Use complex decongestive therapy with multilayer inelastic bandaging and manual lymphatic drainage 4
• Goal is to reduce volume of lymphedema 4
• Measure limb perimeters or volumes objectively to evaluate effectiveness 4

Phase 2: Maintenance Phase

• Use elastic compression stockings or sleeves, possibly associated with MLD 4
• Continue skin care and exercises 4
• Goal is to maintain volume reduction achieved in Phase 1 4

Phase 3: Withdrawal Phase

• Gradual transition to self-management 4
• Annual evaluation is necessary to monitor for progression and adjust treatment 3

Prevention of Recurrent Infections

For patients with recurrent cellulitis/erysipelas:

• Monthly intramuscular benzathine penicillin 1.2 million units in adults 3
• Alternatively, oral prophylaxis with erythromycin 250 mg twice daily or penicillin V 1 g twice daily 3
• Provide patient-initiated therapy with oral antibiotics to reliable patients to start immediately at first signs of infection 3

Weight Management

• Weight loss is recommended for overweight or obese patients, as obesity is a significant risk factor for lymphedema development and can exacerbate existing lymphedema 1, 2
• Refer to a registered dietitian for weight management counseling 2

Critical Pitfalls to Avoid

• Do not use diuretics - they are generally ineffective for lymphedema management and physiologically unsound for pure lymphedema 1, 2, 6
• Do not delay treatment, as this leads to progression with increased dermal sclerosis, decreased joint mobility, and functional impairment 1, 2, 4
• Do not fail to treat infections promptly, as inadequate infection management significantly worsens lymphedema 1, 2
• Do not attempt treatment without specialized training - CDT must be delivered by trained specialists 2

Advanced Treatment Options

If conservative treatment is insufficient after adequate trial:

• Consider referral for microsurgical interventions, which have shown effectiveness when conservative approaches fail 1, 2
• Low-level laser therapy can be considered for reducing limb volume and improving quality of life (Grade C evidence) 1
• Circumferential suction-assisted lipectomy has shown promise for long-term relief in selected patients unresponsive to conservative therapy 7