Lymphedema Related Infections
Patients with lymphedema have a greater risk of getting infections. There are several types of infections that lymphedema patients may experience, and many other conditions that might be confused with infections.
Types of Infections
- Fungal infections: Skin folds that touch often can develop moisture buildup from sweat. This can cause skin breakdown and lead to fungal growth and infection in the macerated tissue. Fungal infections can also increase risk of secondary bacterial infections. It is very important to keep skin fold and toe webbing areas clean and dry. For large skin fold areas, it is recommended to lift and clean the area, dry carefully but thoroughly, and then use a skin barrier such as dimethicone or zinc based cream (creams used for diaper rash bind to the skin and work as great periwound barriers). If there is any fungal infection starting, antifungal cream should be used. Also, some patients find using an unfolded 4”x4” gauze or clean strip of fabric can help reduce risk of moisture buildup. One of the most common areas for fungal infections to start is between the toes, and becomes an important site for infections to start. It is very important that patients with lymphedema have meticulous skin care to reduce their risk of wound development, maceration, and secondary infection.
- Erysipelas (bacterial infections): Erysipelas is a superficial infection of the upper dermal layer of the skin and superficial lymphatics. The vast majority of erysipelas cases are caused by beta-hemolytic streptococci (“strep”). Infection presents with erythema, increased edema, and warmth. Erysipelas typically has more distinctive features than cellulitis in that in erysipelas the infected area is generally raised above the level of the surrounding skin, and has a more clear line of demarcation between involved and uninvolved tissue. Erysipelas patients often have acute symptom onset and associated symptoms of fever and chills. In general, erysipelas is more often seen in younger patients and older patients.
- Cellulitis: Cellulitis is an infection involving the deeper dermis and subcutaneous fat. Cellulitis can be caused by a wide range of organisms including stapholococci (“staph”), beta-hemolytic streptococci (“strep”) and gram-negative bacteria. Cellulitis presents with erythema, warmth, and edema. Infection can be mild and respond to oral antibiotics, or be severe and lead to general infection requiring IV antibiotics and hospitalization. In the presence of lymphedema, infections tend to be more severe.
- Lymphangitis: Lymphangitis is inflammation of the lymph channels and is most commonly an infection after bacteria enter the body from a skin wound or abrasion distally in the limb. Lymphangitis can occur in the setting of normal lymphatics, damaged lymphatics from surgery or radiation, or congenital abnormal lymph vessels. Clinically, lymphangitis typically presents with red streaks with pain and rapid spread. There is often nodular swelling along the course of the lymphatic vessels. Lymphangitis will require aggressive treatment with antibiotics.
Other conditions that could be confused with infections
- Contact Dermatitis: Generally itchy, red, inflamed skin caused when the skin develops an allergic reaction after being exposed to a foreign substance. Contact dermatitis can occur under compression. Use dimethicone or urea based creams under compression to reduce risk of contact dermatitis. OTC steroids can be used under the dimethicone or urea based creams for additional benefit and to reduce heat rash type dermatitis and reduce itching.
- Acute Gout: An intensely painful arthritis condition that usually starts by affecting a single joint, most frequently the big toe, ankle, or knee. Acute gout can be swollen, red, and very painful, and looks very much like an infection.
- Vasculitis: Inflammation of the blood vessels
- Insect Bite: Insect bites can cause cellulitis, but they can also cause a sterile inflammatory response due to toxin release from the venom which can mimic an infection, especially in spider bites.
- Lymphedema Rubra: Lymphedema rubra is a clinical finding of blanching redness of the skin that can mimic and be mistaken for cellulitis. It is commonly seen in patients with lymphedema or phlebolymphedema. If often is confused for infection, and sometimes patients will comment “I was on four rounds of antibiotics but my limb is still red.” Lymphedema rubra is caused by histamine release and inflammatory hyperemia as the body tries to process and remove inflammatory lymph proteins from the skin tissues. It can be distinguished from infection in that it is chronic, does not respond to antibiotics, does not spread or change in size quickly. If both limbs are affected it will have symmetrical distribution. Lymphedema rubra often presents with milder color change than infection and possibly more pink in coloration. Lymphedema rubra indicates an inflammatory process that can lead to tissue fibrosis over time and indicates that the lymphedema is under suboptimal control.
- Folliculitis: Folliculitis is an inflammation of the hair follicles. It presents with small red dots around the base of the hair follicle. It is commonly caused by irritation, but can be caused by bacteria or even fungal infections. Good skin care hygiene and reducing friction to the area can reduce risk of development of folliculitis.
- Intertrigo: Intertrigo is caused by moisture and typically occurs between the toes and skin folds. It appears as a white discoloration with a shedding top layer of skin. Treatment consists of washing with a mild soap and drying well. Intertrigo can develop into a fungal or bacterial infection if not treated promptly.
Know the signs of infections
Infections are dangerous to anyone, but especially for patients with lymphedema. Make sure your patients clean all cuts, scrapes, and insect bites and keep a bandage on them. It’s a good idea for them to keep a small first aid kit with them when they travel or are outdoors.
Signs of wound infection
All open wounds are contaminated quickly with bacteria, but this does not mean the wound is infected. Normal healing can still occur. An infection occurs when the bacteria growth increases significantly and the bacteria start migrating from the wound surface into adjacent body tissues. It is important to realize that infection is actually a clinical continuum. Only surgical wounds are sterile, and if exposed to air they will start contamination within hours to days. Colonization occurs when bacteria are growing on the wound bed. Bacteria use exudate from the wound for nutrients. The more bacteria growing on the wound bed, the more they take nutrients from the wound, and leave toxins and waste products that will slow or halt healing. A wound becomes critically colonized when the bacteria start migrating deeper into tissues. Research has taught us that critical colonization occurs around 105 bacteria per mm3. When more bacteria than this occupy a wound area, local and then systemic infection occur.
Classic signs of infection include
- Increased pain around the wound bed
- Erythema or warmth, or lymphangitic streaking
- Fever / chills or other systemic symptoms
- Purulence or pus draining from the wound bed
- Increasing malodor to the wound bed
- Increased induration around the wound bed or swelling around the wound bed
Not all infections start with the classic signs listed above. If too many bacteria start growing on the wound bed, the bacteria start using up local resources and the wound bed can stall in healing or deteriorate. This increases risk of further wound infection. Secondary signs can progress to infection quickly or may continue low grade without further progression for many weeks. Secondary signs of infection in a wound bed include:
- Increased drainage from wound bed.
- Delayed wound healing
- Discoloration of granulation tissue
- Friable granulation tissue (granulation tissue that bleeds more easily)
- Foul odor to wound bed
- Wound breakdown / enlargement
How to reduce risk of infection in your patients
- Good skin care. This is very important. Skin should be washed with soap and water and rinsed with normal bathing intervals (3-7 times a week). Moisturizers should be used generously in order to help keep the skin soft, supple, and well hydrated. Skin cracking due to dryness increases infection risk. In dryer climates or during cold winter months where the air is dry this is likely more needed. Petroleum based barriers are excellent at retaining moisture. Dimethicone skin barriers and urea based creams are also excellent choices.
- Keep skin folds and toe webbing clean and dry. Instruct patients to be on the lookout for macerated skin and fungal infections in between skin folds and toe webbing areas.
- Keep compression garments and bandages clean and dry.