Care of the skin and nails
People are advised to use a mild antiseptic soap. One per cent hexachlorophane is effective in preventing infection and should be used for general bathing as well as for washing the affected areas. A routine rather like that used with hexachlorophane by surgeons can be adopted. The soap is used regularly for it is known to have a persistent mild antiseptic effect on the skin and to reduce skin bacterial counts. There have been occasional troubles in surgical practice usually with surgical scrub nurses but these have been found to be due to the soap rather than the hexachlorophane. It is important to choose a good brand. ‘Cidal’ made by Boot’s has been found satisfactory. People subject to attacks of inflammation in the lymphoedema may be advised to apply surgical hexachlorophane cream regularly to the part after bathing just as the surgeon does to his hands. ‘Phisohex’ made by Pfizer Ltd is suitable for this purpose.
Hardening and cracking of the skin may be countered by the use of a suitable cold cream such as unguentum emulsificans aquosum in proprietary brands. Particular attention should be paid to the areas around the nails where cracking may occur. The nails themselves require special care. They should be cut after bathing while still soft and less likely to splinter. Some people may benefit from the care of a reliable chiropodist provided no over-ambitious paring or cutting is performed.
- Tinea
Infections with Tinea pedis with the consequent breaks in the skin which may allow bacteria to enter are a hazard in lymphoedema. Prophylactic measures must be practised regularly. The person should try to avoid cross-infection in bathrooms by always using his own personal towels and never walking barefoot. A good prophylactic measure is to anoint the feet, particularly between the toes, regularly with an antifungal agent. The natural antifungal agent of sweat, undecenoic acid, is embodied in the proprietary preparation ‘Mycota’ cream (Boot’s) which has been found useful in practice. Established tinea infections, ‘athlete’s foot’, need vigorous treatment and the advice of a dermatologist may be needed.
- Avoid trauma
Even minor injuries and scratches may become dangerous portals of infection in lymphoedema and they must be avoided. Manual workers need to take particular care. Agricultural workers should wear leather boots and leggings to protect the legs. Insect repellants should be used when needed to avoid bites.
- Elevation of the affected part
The person should sleep with the end of the bed elevated 6 to 10 inches on blocks for lymphoedema of the legs. Should this cause difficulties with a double bed a suitable support or pillow under the mattress on the person’s side of the bed may suffice. Specially adjustable beds sometimes electrically operated are available for those who can afford and wish to buy them.
People with oedema of the face should become accustomed to sleeping sitting up as far as possible. The person is advised to rest the affected leg on another chair when opportunity allows her to sit and if possible to rest with the foot up for a period during the day. A variety of comfortable day beds or chairs are now marketed.
People with lymphoedema of the arm should sleep with the affected limb elevated on pillows or in severe cases held up by a sling and towel.
Elevation promotes reabsorption of water into the venous ends of the capillaries. It does not necessarily cause the reabsorption of protein by this route, indeed this can be shown by performing serial estimations of protein in the tissue fluid of a limb during several days elevation in bed. The protein concentration in the tissue fluid rises as water is absorbed, leaving protein behind. However, there is no reason to believe that the lymph pathways are less capable of draining the more concentrated than the dilute lymph. If they can be encouraged by massage and movement to drain more proteinous lymph from the tissues so much the better because the abnormally high numbers of protein molecules in the tissues are one of the main factors in upsetting the filtration mechanism and maintaining oedema.
- Walking
The person is advised that walking or sitting are preferable to standing. When sitting the leg should if possible be elevated.
Injections of hyaluronidase combined with massage were recommended by some authorities in the past with the object of encouraging easier spread of fluid through the tissue so that it might be massaged away.
- External support
Two-way stretch elastic hose is helpful in controlling oedema. The standard hose extends from the webs of the toes to just below the knee covering the heel of the foot. In people with foot or ankle oedema only, it is often unnecessary to make it extend above the lower one third of the leg. In others with more extensive oedema involving the thigh the question arises of using a full length and thigh stocking. This has proved unrewarding. It is difficult to keep up, folds and ridges appear around the knee and these are uncomfortable and restrict the circulation. It is better to concentrate on getting a good fit and support around the ankle and leg.
The stockings should be made to measure and the measurements taken when the limb is in the most shrunken state that can be achieved by elevation and bed rest.
Heavy-duty elastic bandages may be needed to achieve satisfactory shrinking before employing the more comfortable hose for routine use. The ‘Bisgaard’f type of bandage serves well for this purpose.
A new lighter and less conspicuous type of bandage which stays in place very well during exercise is the ‘Cobana’ bandage made by 3M Company.
In general light bandages and elastic net hose sacrifice effectiveness to appearance and are unsatisfactory. Many women feel averse to wearing supporting stockings but they may be persuaded to use them during standing, in housework and other routines, going without them on special social occasions when they may feel particularly self-conscious about them.
People with oedema of the external genitalia are often helped by the use of a well fitting suspensory bandage. Lymphoedema of the male external genitalia responds perhaps better than any other anatomical area to excisional operations and most people are so improved by surgery that support frequently becomes unnecessary. Mild cases in people during the early post-operative period may benefit from the use of a suspensory bandage.
- Diuretics
Diuretics are helpful in mild cases or as an auxiliary measure after operation. They work on very much the same physiological principle as elevation discussed above. Water is removed from the tissues without necessarily removing protein. This is however of some help. Mild lymphoedema may be helped by the use of diuretics taken near the time of the menses in women when the oedema is often worse. In other cases long-term administration may be helpful. In these circumstances a watch must be kept on the serum potassium levels.
- Pain
Pain is unusual in lymphoedema apart from that produced by inflammatory bacterial complications. It is sometimes encountered in the absence of bacterial infection in the early stages of spontaneous primary lymphoedema in young women. It is probably due to distension of the tissues by newly forming oedema fluid as it is not localized over the course of lymphatics. It is usually encountered on the dorsum of the foot, ankle or lower leg and responds well to massage and the usual conservative measures. It may be occasionally necessary to administer mild analgesics such as ‘Panadol’.
