Lipedema - Dr. Reid's Corner
I have received many questions about the relationship between excess weight and lymphedema and the response to last months survey was amazing. It is clear that many people are concerned about the relationship between weight and lymphedema. Another issue that comes up frequently. How to distinguish lymphedema from lipedema. A very good article was published in the April edition of Consultant (2001) 41, 613. The figure demonstrating lipedema is from that article.
Lymphedema and lipedema are often confused. Lymphedema is due to increased lymphatic pressure with accumulation of edema in the subcutaneous tissue. Over time this results in firming or hardness of the tissues that is characterized by fibrosis. In contrast, lipedema results from the deposition of excess fat in the subcutaneous tissues but does not involve lymphatic hypertension or abnormal lymphatic vessels. The excess fat is normal in appearance under the microscope and there is generally no abnormalities of the lymphatic channels. In addition, there is no abnormal accumulation of excess edema or fibrosis in lipedema.
There are several features about lipedema that distinguish it from lymphedema. One of the most notable differences is the fact that the feet are generally not involved in lipedema. The excess accumulation of subcutaneous fat can involve the entire leg but will generally stop at the ankle, leaving a characteristic ring at the base of the ankle where the lipedema stops. Another difference is the fact that the excess fat is generally symmetric so that both legs are involved equally. In many patients, only the lower extremities and the buttocks are involved, with no excess accumulation of fat in the arms, chest or abdomen. Chronic venous insufficiency can cause a similar appearance; however, chronic venous insufficiency results in swelling of the feet and the accumulation of subcutaneous fluid. The pitting edema seen in lymphedema and in edema due to congestive heart failure is generally not seen in lipedema. This is why leg elevation can be helpful to many patients with venous stasis and to some patients with lymphedema, but is rarely helpful for patients with lipedema. The excess fluid seen in venous insufficiency and lymphedema causes darkening and fibrosis of the skin over time. These skin changes are not seen in lipedema. Congestive heart failure can cause swelling in the legs; however, lipedema is characteristically seen in women and generally starts during adolescence. These patients do not have heart failure. Ulcers and recurrent infections are commonly observed in venous stasis and lymphedema respectively, but are rare in lipedema.
Lipedema generally starts slowly during adolescence and progressively worsens over time, especially in patients who gain significant amounts of excess weight. Dieting can result in a normal appearance in the upper body but persistently enlarged legs. Diet control can be helpful in the management of lipedema since it appears that excess fat preferentially accumulates in the lower extremities. Patients with lipedema often have a history family members with disproportionately large legs.
The treatment for lipedema is generally diet control. Excess weight will preferentially accumulate in the lower extremities. However, even strict dietary measures may not result full resolution of the lower extremity accumulation of lipid. Elevation and compression have modest impact since there is no vascular compromise and no interstitial fluid that needs to be removed. Some efforts have been made to treat lipedema with surgical removal of the excess fat. It is too early to determine the long-term effects of these surgical treatments.
Tony Reid MD Ph.D
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