A Challenging Case of Lymphedema- Resolving a longstanding condition through CDT, wound care and patient education

Patient Care

Vol. 31 • Issue 10 • Page 18

Primary lymphedema, and lymphedema in general, is one of the most poorly understood, relatively underestimated, and frequently misdiagnosed diseases of the vascular system. It is often treated ineffectively with diuretic medications.

Lymphedema manifests as swelling when fluid rich in protein, excess water, and products of the immune system accumulate in the interstitial space. Left untreated, patients develop chronic weeping stasis ulcers, skin fibrosis, and increased girth in affected areas.

This case describes the management of a patient with primary lymphedema who developed extensive chronic non-healing stasis ulcers. The patient is an 84-year-old African female who had been treated for lymphedema tarda prior to 1999.

Chronic weeping ulcers had been difficult to manage. The patient had failed compression bandaging therapy per prior medical documentation. There were no documented reasons recorded in the medical record regarding the failure, except that the patient initially improved and then leg ulcers grew worse.

Patient History

Upon referral, the patient’s initial wound size on the left calf was 14 by 10.5 by 0.2 centimeters with fibrin tissue, edema present, pseudomonas bacteria, hypertension, and lymphedema.

The patient’s wounds measured approximately 3 by 12 cm on the left lower extremity, and 32.5 by 11 cm on the right lower extremity. The patient’s nail bed and feet were black, and their temperature was cool.

The patient was referred to our clinic for chronic bilateral lower extremity (BLE) calf ulcerations and lymphedema with elephantiasis verrucosa nostra.

SEE ALSO: Why Insurers Should Cover Lymphedema Compression Garments

The patient’s medical history included previous BLE calf ulcerations, increased serosanguinous exudate, chronic venous hypertension with ulcer and inflammation, cellulitis, other lymphedema, contact dermatitis and other eczema due to chemical products, venous (peripheral) insufficiency, and dermatophytosis of the foot and nail.

The patient’s medication history was recorded. The patient had received previous nursing care for wound management and had been bandaged; however, she had not undergone complete decongestive therapy (CDT) performed by an occupational therapist prior to her most recent care.

Before lymphedema treatment.

Treatment Protocol

The patient’s chronic BLE calf ulcers had developed approximately 11 years ago, and had been treated throughout the Memorial Hermann Hospital System. However, traditional treatment had not been successful for this patient and resulted in decreased mobility, reduced ability to participate in activities of daily living, and increased possibility of infection.

Within the past 4.2 months the patient had participated in CDT treatment with the incorporation of wound dressings to increase the healing and closure process. Our treatment protocol for this case was as follows.

Month 1. An OT evaluation was completed, and wound and vascular assessment was performed. The treatment team educated the patient on the CDT process, removed soiled bandages, and assessed the skin and wound.

The patient’s BLE were cleansed proximal to distal of the wound with soap and water, and the wound was cleansed with saline. Moisturizer was applied to fibrous tissue and antibiotic topical cream was applied to the wound bed and affixed with dressing.

An initial manual lymph drainage (MLD) session was performed and a multi-layer compression system was affixed to the patient’s BLE, consisting of a stockinette, a 1-by-12 cm foam bandage, and 1-by-6 cm, 1-by-8 cm, 2-by-10 cm and 1-by-12 cm short-stretch bandages on each leg to the knees.

The patient displayed one large wound approximately 10 by 5 cm, and three small wounds measuring approximately 1 by 5 cm on the right leg. On the left leg, the patient had one large wound 15.5 by 4.5 cm, and three small wounds measuring 4.5 by 4 cm.

Month 2. Bandages were removed and the skin and wound were assessed. The patient’s bilateral lower extremities were cleansed proximal to distal of the wound with soap and water, and the wound was cleansed with saline. Moisturizer was applied to the anterior aspect of the patient’s BLE.

Antibacterial ointment was applied to the posterior aspect of the patient’s BLE, and nonvascular fibrous tissue was debrided. Antibiotic topical cream was applied to the wound dressing and placed over the wound beds, and affixed with reduced-friction wound dressings.

A session of manual lymphatic drainage (MLD) was performed and a multi-layer compression system was affixed to the patient’s BLE. Lamb’s wool was used to heal a small cut on the patient’s third left toe. The patient was educated on a home exercise plan with bandages donned.

The patient’s right leg had five small ulcers measuring approximately 2.5 by 2.5 by .01 cm, and one large ulcer approximately 14 cm in length. The left leg had four small ulcers approximately 4 cm in length, and 1 large ulcer approximately 16 cm in length.

Month 3. Bandages were removed and the skin and wound were assessed. A new wound arose from scaly skin coming off of the left dorsum of the foot. The BLE were cleansed proximal to distal of the wound with soap and water, and the wound was cleansed with saline. Olive oil replaced moisturizers.

The patient’s wound on the right leg measured approximately 5 by 9 cm, and three small wounds measured approximately 2 by 5 cm. The patient’s left lower extremity wound measured approximately 4 by 14 cm, two small wounds measured 4 by 3.5 cm, and one small wound measured 2 by 3 cm.

Nonvascular fibrous tissue was debrided and topical cream was applied to the wound dressings, which were placed over wound beds and affixed with reduced friction dressings. A session of MLD was performed, a multi-layer compression system was affixed to the patient’s BLE, and the patient was encouraged to perform seated BLE exercises while in the clinic.

Month 4. Bandages were removed. The patient required increased tactile pressure to stop bleeding. The physician was notified, and the treatment team assessed the skin and wound.lymphedema

The patient’s BLE were cleansed proximal to distal of the wound with soap and water, and the wound was cleansed with saline. Olive oil was applied to BLE.

Nonvascular fibrous tissue was debrided, and the patient’s wounds were 90% healed at this point. Two wounds on the RLE measured approximately 1 by 1 by .01 cm. The patient’s LLE had two small wounds measuring approximately 2 by 3 cm. Antibiotic cream was applied to a petrolatum wound dressing, which was placed over wounds and affixed with reduced friction dressing.

A session of MLD was performed, a multi-layer compression system was affixed to the patient’s BLE, and the patient was encouraged to perform seated BLE exercises while in the clinic.

Sustaining Healthy Tissue

This case illustrates the importance of using a multidisciplinary approach to therapy. Success was achieved by combining advanced wound care techniques with complex decongestive therapy.

After lymphedema treatent (photos courtesy Kirk Cowardbey).

Cellulose dressing in combination with topical antibiotic therapy and occupational therapy interventions were pivotal in sustaining healthy skin tissue.

Unfortunately, this patient was admitted to another hospital due to an unrelated injury. Fortunately, physicians there continued lymphedema management and antibiotic therapy. The patient continued to heal and long-term compression garments were prescribed.

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