Lipoedema or Lymphoedema

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Lipoedema or Lymphoedema

Postby patoco » Sun Jun 11, 2006 8:33 pm

Lipoedema or Lymphoedema

Our Home Page: Lymphedema People

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Lipoedema or Lymphoedema

Related Terms: Lipedema, lipedema, lipodystrophy, lipadema, lipo-lymphedema

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What is Lipoedema?

Lipoedema is a medical condition that is often confused with lymphoedema. The individual with this condition may appear to be simply obese and/or to have extremely swollen legs and swollen abdomen. The condition is an uneven distribution of fat cells in the sub-cutaneous regions generally in the legs or abdomen. One major frustration of people with lipodema is that they are accused of being simply "fat," which is absolutely not the case.

Etiology/ Cause:

Unknown

Complications:

Perhaps one of the most critical complication is the acquisition of secondary lymphoedema. The increased weight can crush the lymphatics causing blockages and hindrances to lymphatic flow. Another complication is deterioration of the joints and vertebrae from the excessive weight. Other complications may include varicose veins and/or the deep venous system. Many lipoedema patients also experience a tremendous amount of pain due to the condition and the affects on the body's systems. Other complications may include "pins and needles" discomfort, decreased vascular flow in the affected limbs and a decreased skin temperature in the affected limbs.

Treatments:

There is no known "cure" for lipoedema. Because it is not a medical condition caused by over-eating and improper nutrition habits, diets will not a much of an effect. Neither can the condition be treated with medicines or diuretics.

Treatments that have helped include massage therapy in conjunction with compression bandages, benzopyrones, which includes the use of coumarin. Liposuction has also been used, but the long term success is still open to debate.

Lipoedema or Lymphoedema:

The signs of lipoedema are distinctly differant from lymphoedema. First, swelling does not extend to the feet, but extends from the abdomen to the ankle. Second, the limb texture is rubbery not hard. Third, pitting edema is not present. Fourth, Stemmer's sign is negative and finally infections that plague lymphoedema patients are generally not a problem with lipoedema. The reason for this is that lipodema is not caused by a malformed or damaged lymphatic system.

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Differential diagnosis protocol for lipoedema:

From a member post by "Itobo" of UK Lymph Forums

http://www.uklymph.com/forums/DynaLink/ ... wtopic.php

SECTION A

Proceed to Section B only if the answer is Yes to at least one of the following:

1. Pattern of fat concentrated in abdomen and thighs (pear shape)?
2. Ankles and feet, AND/OR wrists and hands are smaller than would be expected for the weight on the remainder of the body?
3. Reports consistent difficulty in losing weight after just one to four weeks of initial success?

SECTION B

Proceed to Section C if:

A. The answer to two or more of the first six questions is Yes; and/or
B. The answer to one or both of questions 7 or 8 is Yes; and/or
C. The patient is under 30, and the answer is yes to two or more of questions 9-12, and at least one of questions 1-8.

1. Based on your clinical experience, is this person's weight higher than you would have expected?
2. Is there adipose tissue evident in the affected areas, particularly the abdomen and/or the thighs? (cottage cheese skin extending below the buttocks)
3. Is there evidence of a weakened immune system (frequent colds, bronchial infections, onset of asthma, etc.) which is not otherwise explained?
4. Are there joint pains which cannot be otherwise explained (eg. Symptoms similar to gout, without high uric acid levels; pain in the knee, without evidence of arthritis or rheumatic condition).
5. Is the pattern of weight in each leg symmetrical?
6. Does the patient report pain emanating from the adipose tissue, particularly when pressure is applied?

7. Is there edema (pitting or non-pitting) evident on the ankle?
8. Is there a history of cellulitis, sensitivity to sun, and/or adverse reactions to insect bites?

9. Is there a family history of thyroid or hormonal disorders?
10. Is there evidence of flat feet?
11. Is there evidence of papilloma (skin tags) or peau d'orange skin (rough, resembling an orange peel), particularly between the thighs?
12. Is there a family history of obesity that is concentrated among female relatives (cousins, siblings, parents, children, aunts), or is there a diagnosis of lipoedema or lipo-lymphoedema among any close relatives?

In the above, questions 1-6 relate to both lipoedema and lipo-lymphoedema. Questions 7 and 8 relate more closely to lipo-lymphoedema. Questions 9-12 relate to indicators commonly reported by those with one of these conditions.

SECTION C

Continue to this section only if indicated by Section B.

Lipoedema or lipo-lymphoedema (if pitting edema or significant ankle/foot edema is present) should be suspected. Follow up with a one week treatment regimen involving 1.5 hour daily manual lymphatic drainage (MLD), accompanied by day and night-time compression bandaging using short stretch bandages. Treat the leg with the largest measurements. Compare measurements of the treated leg to its pre-treatment size, as well as to the untreated leg.

If treatment results in a reduction in limb volume in the treated limb, follow up with complex decongestive therapy regimen (MLD, short stretch bandaging, skin treatment, and compression garments following the completion of treatment). For lipoedema, the normal treatment period is 2-4 weeks with 1 - 1.5 hours of treatment daily, six days per week. For lipo-lymphoedema, the normal treatment period is 3-4 weeks with 1.5 - 3 hours of treatment daily, 6-7 days per week.

NOTE: Lipoedema and lipo-lymphedema can also occur in the arms and chest. Normally, abdominal and thigh deposits will also be evident when this occurs. However, this is not always the case.

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LYMPHOEDEMA ASSOCIATION OF AUSTRALIA

Recognition, Diagnosis and Treatment of Lipoedema Vs. Lymphoedema

Lipoedema is a chronic disease of complex causes, many of which we understand little about. These include hormonal imbalance, an inability to metabolise exudate from blood vessels so that those proteins and cells that would normally be metabolised and returned to the circulation are deposited as adipose tissue in the subcutaneous tissue. The blood vessels themselves are affected, venous stasis and vasoconstriction occur and return is diminished especially at the subcutaneous level. This causes arterial constriction which accounts for the cold and often pale skin and leads to an increased lymphatic load(1). The condition worsens over years as tissue channels become progressively narrowed until the condition of a secondary lymphoedema, overlying the original lipodema, may lead to a situation where the patient may be either wheel-chair bound or bedridden. Weight gains can be up to or greater than 250 kgs. At this stage infections and intractable ulcers (or ones that necessitate skin grafts when lack of oxygenation to the skin causes problems with healing) which can be due to the simplest injury e.g. careless donning of a compression garment or other minor trauma, occur with an even higher frequency.

This condition occurs predominantly in women, and can in some cases be familial; the rare cases of men with lipoedema always seem to include a hormonal imbalance which should be treated if possible. The macrophages themselves become overloaded and cease to play an active role in protein proteolysis and look like fat cells.

Lipoedema is often misdiagnosed as obesity in its earlier stages but the symptoms are clear and distinctly recognisable clinically from this. In its later stages it may be more difficult to distinguish from lymphoedema, although the case history and distribution of excessive tissue should provide an indication. The overlying condition of lymphoedema may occur in the later stages. Lipoedema can occur in the legs, buttocks and also, but not necessarily, in the arms. It does not involve either the feet or hands until the onset of lymphoedema. The mean age of diagnosis is approximately 35-36 years but it usually starts at puberty. Symptoms of onset, however, can start in childhood, and may be clinically detectable in adolescence. Cellulite, which is a very mild form of lipodema, usually occurs towards or after menopause. It has been suggested that a mixture of primary lymphoedema as well as lipoedema can occur in some cases.

Differential Diagnosis

Lipoedema

There is symmetrical bilateral enlargement of limbs, both in legs (with buttocks involved) or in both legs and arms, but with the obvious enlargement excluding the feet and hands, until the later stages. Enlargement is a gradual but continuous process.
There is no pitting with pressure. The tissue feels more like "rubber", and is not as hard and fibrotic as in a grade II lymphoedema. It does not, in the early stages, reduce with elevation.

There is pain on pressure, especially in the medial aspect of the thigh and the base of the spine. As the disease progresses, pain is often caused by the lightest of touches to the skin, particularly later in the day. Pain is also caused by "self pressure" e.g. crossing the legs or sitting with pressure on the spine. The abdomen may also be painful to pressure.

Stemmer's sign is negative; i.e. a skin fold test done on the second toe. If it comes up as a thin fold test when "pinched", no lymphoedema is present. If it is a "lump" this indicates lymphoedema.

Superficial capillaries are easily damaged i.e. the limb bruises easily.

Skin temperature is lowered. Hands may feel clammy (damp), but limbs are cold. General nourishment of the skin is also affected and may cause "patchy" skin, dry in one place, oily in others in the early stages. Skin elasticity is reduced and it usually has an "orange peel" appearance.

"Pins and needles" are common and movement seems to alleviate these to a large extent. A feeling of dizziness may be present. There seems to be a reduction of venous return in the legs when standing which can lead to fainting; this may be prevented by walking.
There is little or no loss of weight with rigorous diet. Many of these patients have eaten low calorie diets for many years. In some cases their stomachs have been stapled because of misdiagnosis. In some of these cases, this seems to have lead to the onset of stomach cancer. It is not the answer to the problem! Obesity, caused by overeating, does respond to a proper dietary regime; lipodema does not.

Joint pains (especially in knees) are common.
Infection of the limb, either bacterial or mycotic is not normally a problem.

Plantar support is reduced i.e. people have fallen arches.
The shape of lipodema may vary, from a inverted "pear" shape (like a classical Greek column) to a more bulbous shape from the ankles upward. (Figs. 1-2.) This also usually involves the buttocks.
Lymphoscintigraphy i.e. time of clearance of a radio-tracer injected into the feet to the inguinal nodes, is normal.

Secondary Lymphoedema Accompanying by Lipoedema in the later stages.

Stemmer's sign becomes positive.

Pressure will cause pitting, and there may be a small reduction with elevation.

Folds of skin will further enlarge and feet will swell (Fig. 4.). If arms are affected hands also will swell. If the top of the body is affected the shoulders, thoracic and neck area may be affected as well.

Infection may become a problem.

Diagnosis can normally be achieved by the taking of a careful case history and clinical observation (see above). In the later stages lymphoscintigraphy may clarify this, but the picture is so different from primary lymphoedema that this should seldom be necessary.

Psychological Problems

All of these patients present with a variety of these problems ranging from lack of self-confidence to lack of confidence in their medical or health workers, often because of misdiagnosis and lack of sympathy, and then to real depression and anxiety and because of their appearance and the lack of understanding of the condition, particularly as their mobility decreases. The whole problem, of course, becomes worse if the onset of lymphoedema further exacerbates the condition.

They are "blamed" for being overweight, told they eat too much or are "cheating" on their prescribed diets. If they are hospitalised for a weight loss program when the situation becomes very serious and they don't lose weight, they are often met by the comment "I am surprised" by their health care professionals and are summarily dismissed as "patients for whom nothing can be done" or "we don't know what is wrong with you" or "you'll just have to live with it". This is not helpful to the patient who should be made aware that the condition is a genetic abnormality and that their obesity is not their fault. Of course, up to a point dieting can help but it will never cure this condition. They obviously, and for good reason, become discouraged and dismayed by their problems, which seem not even to be recognised. When lymphoedema occurs on top of the lipoedema this is a situation which is almost a problem that is so great for them (and again often undiagnosed as such) that they need to be very strong people to cope with it. Sadly, many are not able to do this. Psychological counselling can be helpful; for this poorly understood condition it is seldom offered. Invalid Pensions are not the answer for those that have, until they could not, lead an active and productive life. In many centres in Australia and I am sure worldwide, these patients are turned away from treatment centres (for lymphoedema) as untreatable cases. In some cases they resort to surgery in a final effort to improve their condition. The result of some of these operations (including liposuction and limb reduction) are so appalling that they have to be seen to be believed.

Treatment

Lipoedema can be treated and reduced with careful massage to the normal nodal groups after the truncal areas have been precleared i.e. the superficial inguinal and axillary nodes, then gentle superficial drainage towards these. and compression applied to the legs in the form of bandaging as garments. Although not as easy to treat as is lymphoedema, considerable reduction, easing of pain and improvement in mobility, can be of huge physical and psychological benefit to the patient. Compression bandaging is tolerable, especially after a few days of massage. The overlying lymphoedema, if present, can be greatly reduced. The improved mobility will increase the ability to exercise which will help the calf muscles pump and increase venous and lymphatic return. After the initial decongestion by manual drainage permanent compression causes a significant reduction in adipose tissue and also has a positive influence on the disturbed veno-arterial response.

Benzo-pyrones seem to help this condition considerably, presumably by their stimulation of macrophage numbers and activity. Many patients have reported a considerable weight gain when coumarin became unavailable in Australia. Interestingly, the Italian product CellaseneÔ which is recommended for cellulite, contains benzo-pyrones and other plant extracts that work in a similar way to benzo-pyrones, so despite medical scepticism, this may help in these conditions. Unfortunately the cost of these and other available benzo-pyrones are too high for many people who would benefit from them.

The only diet which may help is a very low protein only diet (250 mg per day) (and nothing else, except, of course, water), which will put the body into a state of ketosis where some of the excess fat may be metabolised. However this usually results in weight loss in already lean areas e.g. the waist and often the upper body. Operative procedures do not attack the cause of the problem. Careful liposuction may produce immediate reduction but considering the destruction of tissue it causes, long term results have not been clinically proven. Other reduction operations are contraindicated. Pumps are normally intolerable because of the pain they cause, and there is no published evidence of them ever being successful in this condition.

Lymphoedema

Causes of secondary lymphoedema are frequently obvious from case histories and have been discussed already. However primary lymphoedema varies from lipodema in the following aspects.

1. Swelling is a-symmetrical. Indeed, often only one limb is affected, and the swelling clinically apparent (Fig. 5.). If a leg is lymphoedematous the foot is involved. The hand is usually involved with primary lymphoedema of the arm. Lymphoedema all over may present as more symmetrical but the feet are involved from onset.

2. In the early stages pitting may be present and it may reduce with elevation.

3. It is not painful on pressure. The only time pain is experienced is during an episode of infection. If swelling is rapid in the early stages of secondary lymphoedema this is frequently painful.

4. Stemmer's sign is positive.

5. The limb does not bruise easily, as it does in lipodema.

6. Skin temperature is higher in the lymphoedematous limb/s.

7. "Pins and Needles" are rare in primary lymphoedema, (although both these and paraesthesia may occur in secondary lymphoedema). Venous return is usually normal.

8. Dieting will not reduce primary lymphoedema.

9. Knee joints may be affected by both lymphoedema and extra leg weight and may cause pain such as arthritis. The condition is often diagnosed as this and under investigation is pathologically similar.

10. Infection (both bacterial and mycotic), especially in the later grades of lymphoedema may be a considerable and ongoing problem, and cause an exacerbation of the lymphoedema.

As lymphoedema progresses from Grade I, there is excess fibrotic tissue (collagen), adipose tissue, (especially in primary lymphoedema), and a proliferation of other cellular and interstitial tissue elements. The limb ceases to pit with pressure, feels hard to the touch and much less "rubbery" than pure lipodema. As with lipodema, diagnosis can be clarified both with case histories and lymphoscintigraphy.

Psychological Problems

Lymphoedema can cause psychological problems as well as lipodema. These range again from concern and depression about appearance, to anxiety about the worsening of the condition and of infection, to depression, break-up of relationships with partners, especially if genital lymphoedema is involved etc. etc. This is balanced by the fact that many patients are now aware that some forms of treatment can be obtained, especially if they can afford it, or have Health Cover to assist them. In many areas the public patient is very poorly catered for. Despite these problems lymphoedema patients are usually less "psychologically fragile" than those with lipodema, partly due to the psychological abuse and mockery that many of the latter have suffered.

Treatment

Complex decongestive therapy (skin care, lymphatic drainage by massage, compression and exercises) are accepted as the best treatment for lymphoedema. Because of the inadequate lymphatic drainage and lack of nodes and with abnormal and fewer lymphatic vessels, drainage needs to be taken to truncal quadrants where lymphatic drainage is more normal. This of course depends on the individuals situation. What drainage that does exist in a limb should also be enhanced by massage. Pumps should never be used in primary lymphoedema. Surgery, unless in very skilled hands, is seldom beneficial in the long term.

Acknowledgement

THE LYMPHOEDEMA ASSOCIATION OF AUSTRALIA, INC.

www.lymphoedema.org.au

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Lipoedema - status, new perspectives current
Journal of the German Dermatologi society
Volume 2 Issue 3 PAGE 181 - March 2004
doi:10.1046/j.1439-0353.2004.04051.x
Summary
Due to the lifelong, usually progredienten process and the pronounced suffering pressure the Lipoedem is an important dermatologisches disease picture. By years ago the complexes introduced as standard treatment physical Entstauungstherapie can be obtained a clear acceptance of illness-typical edemas. As new effective procedure the Liposuktion in Tumeszenz local anaesthesia with vibrating Mikrokanuelen proved. A purposeful and durable reduction of the disproportionate Fettgewebsanteile help the concerning due to the improved appearance, the edema reduction and the pain removal to a pronounced improvement of the quality of life.

Summary 2

Because OF the lifelong and often progressive course and the mentally trauma ton the patients, lipoedema is important on dermatologic more disorder. Complex physical therapy programs were introduced as A standard therapy years ago and CAN achieve to impressive oedema reduction. Liposuction in tumescent local anesthesia with vibrating microcannulas has proved tons A new effective treatment. A targeted and permanently reduction OF the fat tissue leads tons on increased quality OF life due ton on improved appearance, reduced tendency tons swelling and less pain.

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