Lymphorrhoea

Lymphorrhoea is most commonly associated with cancer-related lymphoedema, however, it can happen to people who have lymphoedema from any cause. Lymphorrhoea represents a change in the nature of swelling that means that the pressure inside the tissues is so high that the skin can no longer contain this. The result is that beads of fluid leak from the skin. Lymphorrhoea often represents a sudden change and therefore, to be able to manage this effectively, it is important to establish why it has occurred in the first place.

Lymphorrhoea looks straw coloured. There does not necessarily need to be a knock or scratch to the skin to make this leaking happen, however, often the skin at this stage is so tense with fluid, a very minor knock can result in a wound, which can lead to significant leaking. If a knock has occurred some blood might be mixed too.

The most common place for lymphorrhoea to occur is the legs, but it can affect any area of the body.

Common causes of lymphorrhoea are:

• Leg dependency (i.e. sleeping in an armchair or spending all day in a wheelchair)
• Immobility (i.e. suddenly changing to being very sedentary where you were normally very active)
• Not using compression garments or bandages if you need them
• Changes in medical health such as breathing difficulties or cellulitis
• Low protein levels (known as albumin)
• Cancer (sometimes because of cancer progression, sometimes when the body is weakened by successful treatment)
• Secondary to cellulitis

Lymphorrhoea is more likely to occur when several factors happen together; for example, if someone who has lymphoedema of the legs then develops a severe chest infection, several of the above risk factors occur in quick succession. The fictional case study below demonstrates how this could occur:
Mr Jones has long standing asthma. He also has primary lymphoedema of his left leg. One Autumn, he developed a chest infection. This resulted in him feeling very short of breath, weak and tired. As his coughing was worse when he tried to lie down, he spent a few nights sleeping in the chair downstairs, partly as his sleep was unsettled and partly so his wife could sleep. As he felt weak, he was not moving around much during the day. He also found the effort of pulling on his compression stocking made him cough, so for a few days he left them off. After around four days, lymphorrhoea developed.

What can you do to prevent lymphorrhoea?

• Get appropriate, ongoing advice and treatment for your lymphoedema (treatment and knowledge changes over time; keep going back to your lymphoedema practitioner, if you have one).
• Skin care: ensure the skin is washed, dried and moisturised each day.
• Exercise at your level: For some, this might be running a marathon, for others, it might be having someone else help the swollen limb bend and stretch (this is known as passive exercise).
• Maintaining a healthy weight can help improve lymph and venous return.
• Elevation of the affected area: ideally to the same level as the heart when you are resting.
• Wear your compression (garments or bandages) as advised by your therapist.
• Self or assisted lymphoedema specific massage (Simple Lymphatic Drainage or Manual Lymphatic Drainage).
• Ensure your medical health is as good as possible and any conditions such as high blood pressure are well managed*.
• Eat a healthy, well-balanced diet.

A lymphoedema therapist can advise on more specific treatment pathways designed specifically for you.

Key Note:

*It is worth knowing that Calcium channel blockers (a group of drugs often used to help control high blood pressure) and other drugs such as steroids can make swelling worse. If you are on this group of drugs it might be worth discussing this with your GP. However, do not stop taking them without discussion as poorly controlled blood pressure can be more dangerous for your general health.

Should lymphorrhoea occur, it is essential that you get help promptly. The next working day is OK. You should not need to call a doctor or go to Accident and Emergency overnight unless the skin leaking develops in conjunction with redness, heat or pain in that affected area. If this occurs, there is a high likelihood that you have cellulitis. This requires prompt medical attention either through your GP or, on the weekend, Accident and Emergency.

What to do if lymphorrhoea occurs:

In an ideal world, we would hope everyone should have access to a lymphoedema specialist who can provide appropriate and timely support; however, we recognise that isn’t always the case. In the absence of a lymphoedema practitioner, the following suggestions might be useful.

• With your doctor, try and establish if the leaking is lymphorrhoea and look at what is going on with your general health to see if anything can be improved. There may be medical investigations worth undertaking where there is a sudden change, such as blood tests or a review of your medication.
• Skin care remains essential. When lymphorrhoea gets on the skin, it further damages the skin’s condition. Also, the leaking areas create a portal for infection to get in. This could lead to cellulitis.
• Washing the skin with products such as DERMOL 500 can be good as they are anti-microbal whilst avoiding drying the skin out too much.
• Unless there are open wounds, you can wash or shower normally and you can pat the skin dry with a towel as long as it is clean.
• Dressings: What dressings to use on the leaking areas will vary. The nurse assisting you (this could be a lymphoedema practitioner, practice nurse, district nurse or palliative care nurse) will assess the amount of leaking and look at your skin generally. There are thousands of products available and no single one has been found to be the best.

Ideally any dressing should:

• Absorb the moisture and hold it away from the skin to prevent further skin damage.
• Be non-adherent to avoid damaging the tissues at times of dressing change.
• Compression bandaging is the most important element of care. At this stage, the skin is too fragile to simply go into compression hosiery.
• If there is lots of leaking, the bandages and dressings may need changing several times a day initially. Although this can seem laborious, good care early on can result in the areas healing within a few days. More complex lymphorrhoea can sometimes persist for longer though.
• Once the skin is better, compression garments should be resumed to prevent the lymphorrhoea re-occurring.
• Elevation and exercise remain important.
• Elevation really does mean elevating the affected areas to the level of the heart. Where this isn’t achievable, elevation as far as is practical and comfortable is still worthwhile. This can be achieved by resting on the sofa or a recliner chair.
• Exercise is harder when bandages are on, but keeping as active as possible is still important. Simply bending and pointing the foot is great for helping lymph flow. Bandages and compression stockings all help the most when the muscles are moving against them.

Sometimes, it is possible that you could learn how to change the dressings and apply bandaging either by yourself or assisted by someone close to you. If you choose to do this, try not to lose contact with a qualified health care professional who can oversee what is going on and who will be able to advise you when it is time to change tact. They can also answer any questions you have or problems that need to be addressed. Please let your nurse know if you want to be more involved in your treatment or if you are very nervous of being asked to be involved so that the care plan can be what suits you best.

Other causes of lymphorrhoea:

Lymphangiomas are commonly known as ‘lymph blisters’. They look very much like little blisters and could occur in isolation or in groups. These can happen in primary or secondary lymphoedema. Commonly they appear on the leg, genitals, armpit, fingers or toes, but again, can occur anywhere. In many cases, these can be reduced or reversed by good skin care and compression. For genital swelling, a good starting point is to use lycra based, cotton rich underwear. For women, body control underwear is a good starting point. For men Speedo style (i.e. tight and more Y-front shaped) underwear can be good. Double layering underwear or using padding inside can help provide more compression, but this must be a clean, breathable, non- irritant padding.

If the lymphangiomas become more established, they can become more solid and ‘warty’. When they are new or in moist areas, such as the genitals, these can easily break and lymphorrhoea can occur. In difficult cases further intervention, such as laser or surgery might be worth looking into. At this stage it is essential that experienced medical advice should be sought from a doctor used to managing lymphatic disorders.

Where lymphorrhoea is secondary to cellulitis, it is imperative that the cellulitis is addressed by appropriate antibiotic therapy first and foremost. In the initial stages, if the skin has broken, skin care, dressings, rest and elevation are the most significant interventions. Once the acute cellulitis is settling down, you can start introducing compression (if this is suitable for you). You and your therapist will need to discuss when and how this is implemented and varies from person to person.

Summary

Lymphorrhoea can occur suddenly and in all types of lymphoedema in all areas of the body. There are risk factors and early warning signs. Effective management requires commitment from yourself and the doctors, nurses and lymphoedema practitioners looking after you.

Lymphorrhoea can be managed and in most cases can be stopped, but the earlier it is treated, the better.

Editor’s note: This article was originally published in the Winter 2009 issue of LymphLine. Due to many requests for information on this topic, it is has been reviewed by the author and republished.

Next article: Have you got Cellulitis… or Red Legs?

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