An excellent question was posted on our lymphedema bulletin board regarding diabetes and lymphedema. To follow was Dr. Reid's response to the question, as well as some additional information concerning this topic.

Your question is very good, thanks for posting it. Many diabetics wonder whether diabetes will increase their risk of developing lymphedema or make their lymphedema worse. In addition, many patients wonder how to treat lymphedema when they have diabetes. There are several recent publications that provide some information, see below and Dr. Reid’s corner. However, on the whole there is not much published information on the combined effects of diabetes and lymphedema. Diabetes results in damage to the microc apillaries. Patients with diabetes are at increased risk of developing vascular insufficiency and pressure ulcers. Compression is commonly used to help treat the diabetic ulcers. If properly used, compression can help improve the circulation and relieve the pressure ulcers. It sounds like you already have some vascular insufficiency but fortunately this has not gotten bad enough to cause ulcers. Compression can be very helpful in your case, especially to reduce the edema and reduce the risk of infection. S ince you are a diabetic with lymphedema you are at an even higher risk for infections. Bandages and wraps should be applied carefully. The compression should be firm so that you get sufficient compression to reduce the lymphedema; however, the compression should not so tight that you cause further vascular obstruction. Your doctor or therapist can help you with proper compression. You might want to consider using either the ReidSleeve or OptiFlow CS. The soft, convoluted foam design could be very helpful f or you. The high pressure points provide a gentle, deep-tissue compression while the low-pressure points help to prevent blocking vascular flow. In addition, the pressure is easily adjusted. The Optiflow EC provides the advantages of the ReidSleeve but can be used with bandages. Thanks for your excellent question and I look forward to receiving additional comments from our readers.

What is diabetes and can it make lymphedema worse? People with diabetes cannot regulate the amount of glucose in their blood properly. After eating a meal, the glucose in the blood increases as the food is digested. In response, the pancreas produces insulin which helps the cells in the body take glucose in from the blood. People with diabetes are unable to transfer glucose in the blood into the cells. There are different types of diabetes. In type I, the levels of insulin are low. In type II, the levels o f insulin are normal, but the cells do not respond to the insulin properly. In either type, the result is increased glucose in the blood.

Over many years, the increased levels of glucose in the blood can damage the blood vessels, connective tissue, nerves and organs. In the blood vessels, atherosclerotic plaques builds up resulting in blockage of the large arteries and the small vessels are damaged so that they do not transfer oxygen properly to the tissue. These vessels can become leaky. Poor blood flow can result in damage to the skin and connective tissue resulting in sores and infections. These complications are treated with medications to increase insulin or improve uptake of glucose into cells. Excess weight can worsen diabetes and weight control is an important component to the management of diabetes. Pressure sores and infections are treated with antibiotics, protective bandages and compression.

Patients with lymphedema have leakage of lymphatic fluid into the tissue causing swelling and connective tissue damage and increased risk of infection. While diabetes generally causes damage to the arteries and capillaries, lymphedema is the result of damage to the lymphatic system. Together, these diseases result in damage to both the arterial and lymphatic systems and both lead to damage to the subcutaneous tissue, connective tissue and skin. The result is increased swelling, decreased levels of oxygen i n the skin and connective tissue and susceptibility to infection.

Effective treatment of the tissue swelling requires compression that can get to the deep subcutaneous tissues without obstructing the lymphatic and venous outflow. That is why the high and low pressure exerted by the the ReidSleeve and Optiflow is so effective in treating lymphedema and other swell disorders. The technology is designed to apply effective pressure to the skin, subcutaneous tissue and the connective tissue of the deep dermis.

Tony Reid MD Ph.D

J Wound Care 1999 Jan;8(1):5-10
Chronic wounds and nursing care.

Lindholm C, Bergsten A, Berglund E

Department of Nursing Research, Uppsala University Hospital, Sweden.

This study has collated data on the prevalence of chronic wounds and the demography of patients with these wounds. Diagnostic methods, nursing care, the presence of diabetes and pain are analysed, as well as data on healing, amputation and mortality three months post-study. A total of 694 patients were identified: 406 with leg or foot ulcers, 117 with pressure ulcers and 171 with other wounds. Most patients were treated in the community. Leg ulcer aetiology was verified with ultrasound Doppler examination. There was a correlation between low Norton score (< 20) and severity of pressure ulcer (Stage III or IV). The use of 113 different wound dressings or combinations of products was reported. Time spent on dressing changes was the equivalent of full-time employment for 57 nurses. Wound cleansing was not predominantly performed with tap water, as recommended, but with saline. Almost all patients with venous leg ulcers (88%) were treated with compression but in 35% of these support stockings were used. Pain wa s present in almost half of all patients, more commonly in Stage III or IV pressure ulcers than in Stages I and II, and was most often reported in older patients. Diabetes was present in 25% of all patients with leg and pressure ulcers, and in 57% of patients with foot ulcers. At three-month follow-up, 28% of pressure ulcers, 40% of leg ulcers and 61% of other wounds had healed. Mortality was 35% in patients with pressure ulcers, 4% in those with leg ulcers and 7% in those with foot ulcers. These data have been presented to politicians in the county, resulting in allocation of resources for a wound healing centre.

BMJ 1999 Jun 12;318(7198):1591-4
Risk factors for erysipelas of the leg (cellulitis): case-control study.

Dupuy A, Benchikhi H, Roujeau JC, Bernard P, Vaillant L, Chosidow O, Sassolas B, Guillaume JC, Grob JJ, Bastuji-Garin S

Dermatology Department, Hopital Henri Mondor, 94010 Creteil, France.

OBJECTIVE: To assess risk factors for erysipelas of the leg (cellulitis).
DESIGN: Case-control study.
SETTING: 7 hospital centres in France.
SUBJECTS: 167 patients admitted to hospital for erysipelas of the leg and 294 controls.
RESULTS: In multivariate analysis, a disruption of the cutaneous barrier (leg ulcer, wound, fissurated toe-web intertrigo, pressure ulcer, or leg dermatosis) (odds ratio 23.8, 95% confidence interval 10.7 to 52.5), lymphoedema (71.2, 5.6 to 908), venous insufficiency (2.9, 1.0 to 8.7), leg oedema (2.5, 1.2 to 5.1) and being overweight (2.0, 1.1 to 3.7) were independently associated with erysipelas of the leg. No association was observed with diabetes, alcohol, or smoking. Population attributable ris k for toe-web intertrigo was 61%.
CONCLUSION: This first case-control study highlights the major role of local risk factors (mainly lymphoedema and site of entry) in erysipelas of the leg. From a public health perspective, detecting and treating toe-web intertrigo should be evaluated in the secondary prevention of erysipelas of the leg.

Lymphedema Case Study D.S.
Healthtronix Lymphedema Treatment Center
Susie Wills, BSN, RN, CLT
Director of Clinical Services

PATIENT INFORMATION: Ms. D.S. is a 44 y/o female who presents with LE in her (L) arm secondary to treatment for Hodgkin's disease.

DIAGNOSIS: Pt was 18 y/o in 1972 when she was diagnosed with Hodgkin's disease. At that time she received radiation which alleviated the cancer. However, in 1977, the patient again was diagnosed with Hodgkin's and at that time received surgery and chemotherapy. She reports that she first noticed edema in her arm in 1980. She presented on 9/18/98 with 21.6% more volume in her (R) arm as compared to her (L) arm.

PREVIOUS TREATMENT: Pt. had had no treatment for her LE, but had obtained a compression sleeve, which she had worn off and on for years, and that did not fit her arm well.

EXACERBATION: Ms. D.S. is a remarkably fit 44 y/o who had been lifting weights, doing long sequences of pushups, and had just finished taking Navy Seals Training. During this training, she had sustained scratches and insect bites on the arm and had performed rigorously strenuous exercises.

OBSERVATION: On assessment, pt. did have significant edema of her (L) UE. Several minor abrasions were noted, as well as, red, raised areas which appeared to be insect bites. Pt. was unable to say how much of an increase of LE had occurred recently, but was experiencing much discomfort in the limb. She described the arm as feeling extremely stiff, achy, hard, heavy, tired and painful.

TREATMENT: Her treatment plan consisted of MLD/CDT X 20 treatments. Pt. broke down into tears when the compression bandage was applied and asked that it be removed immediately. She stated, "I can't live like this!" After talking with the patient at length, it became apparent that she would not be persuaded to wear bandaging or to self-bandage. The patient admitted that she had always been in denial of her LE, and that this was more than she could take in. We discussed the pros and cons of continuing MLD th erapy without bandaging. Together we designed a treatment plan that the patient could accept and that would hopefully be effective with her LE. The patient was fitted for a proper fitting compression sleeve and a Reid sleeve. As soon as these were obtained, the pt. had MLD daily and then wore her compression sleeve during the day and her Reid sleeve at night, and with an exercise and breathing regimen. She also attends a monthly LE awareness group and has joined the NLN.

RESULTS: Ms. D.S. was treated from 9/18/98 to 10/29/98 and at the end of her treatment, she had achieved an 85% reduction of her lymphedema and was pain free. The volume of her affected arm had decreased from 21.6%, as compared to her unaffected arm to, 3.2%.

HOME PROGRAM: The patient was discharged on 10/29/98 with a home maintenance program which consisted of wearing her compression sleeve during the day and her Reid Sleeve at night, and limb and breathing exercises. She also attends a monthly lymphedema awareness group and has joined the NLN.

PROGRESS: Goals were met with this patient despite the alteration in the conventional treatment plan. Had the alterations not been made, the patient would have refused treatment, and I believe would have suffered a major exacerbation. It has been very difficult for her to accept her LE but she has maintained the progress despite episodes of non-compliance with her maintenance program and strenuous exercise.

FOLLOW UP: The patient received a prescription from her physician for monthly PRN visits for MLD, but has not yet had to return. I do see her monthly at the awareness group and follow her progress.

For this and other case studies, look at our Clinical and Case Studies page.

In a previous eNews we let you know about an upcoming conference and would like to take the time to remind our eNews subscribers that space is limited, but registration is still open for those who would like to attend. This should be a great conference. The focus of the conference is on modern concepts in identifying and treating lymphedema. Some of the topics that will be discussed are:

Pathophysiology
Early Intervention
Medical Management
Current Modalities
Problems vs. Solutions
Providing the patient with Independence and Quality of Life
Psychosocial Effects of Lymphedema
Wounds and Their Relationship to Lymphedema
Looking Beyond the Wound
Lymphedema Case Management

The Conference will be located in DALLAS, TEXAS on March 4th & 5th, 2000 at DoubleTree Hotel - Lincoln Centre. For more information call 1-800-349-9490 or Dallas area 972-881-5535

Dr. Tony Reid will be the keynote speaker and many of us from Peninsula Medical are planning on attending. We hope to meet some of you there!

For complete information and registration information online, click here.