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An Overview of Lower Limb Lymphoedema and Diabetes

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An Overview of Lower Limb Lymphoedema and Diabetes Clinical REVIEW An overview of lower limb lymphoedema and diabetes Caroline McIntosh, Tracy Green The prevalence for individuals diagnosed with lower limb lymphoedema and coexisting diabetes is unknown. However, both conditions cause significant problems that can compromise the viability of the lower limbs. An extensive search of the literature including medical databases (MEDLINE, PubMed and CINAHL), plus hand searching through diabetes journals, podiatry journals and wound care journals, was undertaken to search for published literature relating to diabetes and lymphoedema of the lower limb. Prevalence subcutaneous tissues (Yosipovitch et al, Key words Lymphoedema/chronic oedema are 2007). significant causes of morbidity in the Lymphoedema general population. An epidemiological Obesity is increasingly being Lower limb study completed by Moffatt et al (2003) recognised as a major public health Diabetes aimed to determine the magnitude of the problem. The Department of Health Foot problem and the likely impact on health (DoH) (2008) stated that, ‘obesity resources, employment and patients’ is both a highly complex issue for quality of life. The study, which was carried society and a costly debilitating lifestyle out in a primary care trust in south west disease’. Health survey information for London, identified a crude prevalence England, undertaken in 2006, found ymphoedema is a chronic of chronic oedema of 1.33/1000. This that a quarter of the adult population progressive condition for which increased to 5.4/1000 with age (>65 in England are classified as obese, along Lthere is no cure. Unless it is years) and was higher in women. with almost a fifth of all children under managed effectively, lymphoedema can the age of 16 (DoH, 2008). Obesity is, gradually deteriorate and treatment Risk factors therefore, one of the major public health can become increasingly difficult. Many risk factors for lymphoedema have issues in the developing world and is Lymphoedema and chronic oedema are been identified, including non-accidental known to contribute to an increased risk terms that are often interlinked. injury, such as venepuncture (Cole, of heart disease, some cancers and type 2006) and chronic health problems 2 diabetes mellitus. Harwood and Mortimer (1995) linked to obesity, such as diabetes, define lymphoedema as: ‘The hypertension and cardiovascular disease Diabetes mellitus accumulation of lymph in the interstitial (Soran et al, 2006). Diabetes is an escalating problem in spaces caused by a defect in the lymphatic the UK, which may contribute to an system.’ It is marked by an abnormal Fife et al (2008) reviewed the current increased prevalence of lymphoedema collection of excess tissue proteins, evidence base, including case studies in in time, particularly when linked with oedema, chronic inflammation and fibrosis the absence of controlled trials, and found obesity. There are currently an estimated (Harwood and Mortimer, 1995). that there is increasing clinical evidence to 2.35 million people diagnosed with suggest that morbidly obese patients are diabetes in England (DoH, 2007), while Chronic oedema describes oedema predisposed to secondary lymphoedema it is estimated that a further 800,000 that has been present for more than and that primary lymphoedema can individuals are living with undiagnosed three months (Moffatt et al, 2003). induce adult-onset obesity. However, diabetes (National Institute for Health there is at present limited scientific and Clinical Excellence [NICE], 2004). Dr Caroline McIntosh is a Senior Lecturer at the evidence to determine the mechanisms Department of Podiatry, National University of Ireland, by which these events take place, The prevalence of diabetes is Galway; Tracy Green is a Macmillan Lymphoedema Clinical although it is known that obesity impedes predicted to rise to more than 2.5 Nurse Specialist, Macmillan Unit, The Calderdale Royal lymphatic flow, leading to an accumulation million in England by 2010 (DoH, Hospital, Halifax of protein-rich lymphatic fluid in the 2007). This rise is attributable to both Journal of Lymphoedema, 2009, Vol 4, No 1 49 McIntosh, revised and cut2 C.indd 1 9/4/09 08:33:45 Clinical REVIEW an ageing population and also an Clinical features of lymphoedema obesity with co-existent lymphoedema increasing prevalence of obesity, with that are particularly problematic in the has also proven to be an independent the DoH (2007) figures suggesting that lower limbs include: risk factor for erysipelas (Yosipovitch et approximately 9% of the increased 8 Pitting oedema in the initial stages, al, 2007). prevalence of type 2 diabetes will be progressing to non-pitting tissues as a direct consequence of obesity. It the condition progresses Damstra et al (2008) undertook could, therefore, be postulated that 8 Skin changes, including a small (n=40) study in which the incidence of individuals presenting hyperkeratosis, papillomatosis, lymphoscintigraphy of both legs was with both lymphoedema and diabetes, lymphangiomata, fibrosis (Table 1) performed in patients four months after particularly in obese individuals, will 8 Stemmer’s sign their first acute event of erysipelas. escalate over the next few decades. 8 Skin folds Findings from this small sample 8 Distorted/misshapen limb demonstrated that 79% of the patients An extensive search of the literature, 8 Recurrent cellulitis. experienced sub-clinical lymphatic including medical databases (MEDLINE, dysfunction of both legs, suggesting PubMed and CINAHL), plus a hand Skin changes in the lower limb that lymphatic impairment may be a search of diabetes, podiatry and wound Skin changes secondary to diabetes predisposing factor in erysipelas. However, care journals, revealed that there are mellitus are also common, with while diabetes is a known risk factor currently no published data detailing published data suggesting that as many for erysipelas infection, none of the the prevalence of individuals diagnosed as 30% of all patients with diabetes will participants in the study had previously with both lymphoedema and diabetes. present with skin changes during the had a positive diagnosis for diabetes, thus However, a combination of both course of their disease (Ahmed and limiting the external validity of the study. pathologies in the lower limbs can Goldstein, 2006) (Table 2). compromise the viability of the legs and Fungal infection feet, placing the individual at high risk of The impact of obesity (a common Obesity is thought to increase the risk infection, ulceration and necrosis, and, in precursor to both lymphoedema and of cutaneous fungal infections, such as severe cases, the loss of a limb. diabetes) on the skin has received candidiasis. Individuals with diabetes are minimal attention to date, despite the also known to be at an elevated risk of This article aims to explore the fact that obesity is also associated with fungal skin infection, as hyperglycaemia current evidence-base for diabetes a number of dermatoses, including has a detrimental effect on the immune and lymphoedema and discuss the acanthosis nigricans, keratosis pilaris, system. The skin of individuals with implications of both conditions on the hyperkeratosis and skin striae. lymphoedema and diabetes should be lower extremities. It also considers regularly assessed for fungal infection, the appropriate assessment and Furthermore, obesity can heighten particularly in skin folds or between management strategies to aid nurses and the risk of skin breakdown in those digits, where fungi will thrive in the podiatrists in clinical practice. with poor tissue viability, and complicate warm, moist environment. wound management, particularly for Implications of lymphoedema and diabetes those who are morbidly obese (Fife Furthermore, mycologic tests for for the lower limb et al, 2008). In obese patients with the presence of fungal species may Lymphoedema in the diabetic foot lymphoedema, the accumulation of fluid prove beneficial in those individuals is thought to be a combination form in the lower limbs can lead to fibrosis of with ulceration on the legs or feet and of lymphoedema with a complex the skin, decreased oxygen tension and coexisting diabetes and lymphoedema, pathophysiology – microangiopathy leads macrophage function, which provides as fungal infection can be detrimental to to increased permeability of the blood a culture medium for bacterial growth wound healing if left untreated (Missoni capillaries and an increased lymphatic (Yosipovitch et al, 2007). Diabetes is et al, 2006). load. The effects of diabetes can also also known to predispose individuals to affect the blood capillaries of the lymph infection, as the effects of an underlying Specific manifestations of diabetes on nodes, resulting in a general immune vascular disease on the immune system the lower limb deficiency. Lymphatic failure, due to can result in hyperglycaemia and tissue Patients who have lymphoedema, or inflammation following infection, insulin hypoxia (Falanga, 2005). Therefore, are at risk of lymphoedema, also need injections and ulceration, can also result individuals with co-existing lymphoedema to be educated on the effect other (Földi and Földi, 2007). and diabetes are at heightened risk of conditions and treatments may have infection of the lower limbs. on their condition. Diabetes mellitus It is important to identify patients can have a profound impact on the with coexisting lymphoedema/chronic Bacterial infection lower limb – chronic hyperglycaemia oedema and diabetes in
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