Lymphovenous Canada: Dr. Gary Sibbald talks about dermatology issues facing people with lymphedema

Dr. Gary Sibbald is a dermatologist internist who has been in practice since 1979. He received his training at the University of Toronto and in London, England at St. John's Hospital where he studied diseases of the skin. In 1995 with Cathy Harley, he established the Canadian Association of Wound Care and the Wound Healing Clinic at Women's College Hospital in Toronto.

Dr. Sibbald is actively involved in wound care education as a co-editor of the third edition of Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. He is the head of the course committee for the International Interdisciplinary Wound Care program run by the Faculty of Medicine at the University of Toronto. The course is affiliated with the University of Wales, College of Medicine.

As the population ages, we develop disorders such as lymphedema from previous cancer surgery or secondary lymphedema that result from previous radiation treatment. The biggest challenge we see with lymphedema and wound healing relates to lymphedema of the lower legs. The average age of patients with chronic wounds for persons with diabetic foot problems is about 60 and persons with venous leg ulcers is about 70 years old.

This challenge may also be from individuals with primary lymphedema or persons born with a propensity to develop increased swelling although this swelling may not be apparent at birth, it's often delayed into the teen years and sometimes even into adult life.

The third group we see, are those individuals with venous disease and with venous leg ulcers that are inadequately treated for years and develop secondary lymphedema to chronic venous disease. In this group, good preventative measures and good education would prevent the secondary lymphedema entirely!

Then there's a fourth group that relates to individuals who have increased body weight. In these individuals the venous return and the lymphatic return to the heart is obstructed so that lymphedema develops. This can be a vicious cycle, which requires working with the patient to control the weight problem.

The influence of low albumin in wound healing

When the albumin is under 25 you get some impairment in healing of chronic wounds. When that number is under 20 you don't have enough circulating protein within your vascular system and fluid tends to leak out of the vascular system. This taxes the lymphatics. If the lymphatics cannot handle the increased fluid reserve, then it stays in the tissue. This really sets the stage for, first of all, pitting (finger imprint remains after pressing on the swelling) edema, and with time non-pitting edema, or lymphedema.

Preparing the wound bed

Preparing the wound bed really starts with the patient. You must look at addressing the cause of the wound, but first you've got to remember that you have to treat the whole patient and not just the hole in the patient. We also have to look at patient centered concerns.

Compression therapy is important for lymphedema but there are pain and quality of life issues. Considerations include the warmth and the uncomfortable nature of some of the bandaging and compression garments, particularly during hot summers like the one we've just been through. You've also got to look at the patient's ability to buy bandages, stockings and lymphedema devices which may not be covered by health care or private insurance plans. These items can become very expensive so that individuals cannot afford them. Lymphedema sufferers can end up being fitted before the edema comes under adequate control. When this happens individuals can have a custom made garment which costs a lot of money and might end up not fitting them when their pitting edema is controlled.

Although we have newer biological and adjunctive therapies, our practice in chronic wounds is not ideal. Our approach to chronic wounds includes getting rid of the grunge, looking at the excess bacteria that can sometimes creep up on us, and then examining moisture balance. There are three steps we should look at in trying to adequately prepare the wound bed for healing:

i) adjunctive therapies
ii) enzymatic therapies
iii) other interventions that help the wound to heal

i) Adjunctive therapies:

Debridement can also be done through mechanical means such as a "wet to dry" technique. "Wet to dry" to the lay person means putting saline soaked gauze to the wound, letting it dry out and yanking it off. It causes pain, bleeding and is really not very patient friendly. It is also very nursing time intensive. This process can also be very damaging to the wound because it can leave pieces of gauze behind. It's an older method but is still widely used. One of the reasons it is widely used is because saline and gauze is cheap - but if you look at the nursing time involved it is not a very good treatment for modern medicine when we've got better techniques available.

ii) Enzymatic therapies:

Sometimes the scab on the wound has to be scored with a blade by a health professional to facilitate penetration of enzymes to debride the wound. A scab is dead material and if it is completely necrotic it may be black and hard. If it has increased bacterial growth in it may have an odour.

Once the wound is debrided, the next issue is the bacterial balance. If there's loose slough, smell or very friable granulation tissue (which means it bleeds easily) it's a bright red and almost too good to be true, and the wound stops healing or it has an increased discharge: all of these signs may mean the surface of the wound has too many bacterial cells.

iii) Other techniques:

Fungal/bacterial situations

To prevent fungal infections persons with lymphedema should inspect their feet particularly on a daily basis. That is to make sure their feet are dry between the toes. Fungal infections always start between the fourth and fifth toe and then spreads to the large toe because the fourth and fifth web space is the smallest space between the toes so that it gets the warmest and it experiences the most occlusion and friction.

What you first see in the toe web space is a white overly wet surface scale that we call maceration. Around the edge of that you may see a little rim of scale and may have an active margin. The other thing that may tip us off is a foul odour which usually means that anaerobic bacteria are present. And that of course can be an entry point for infection (cellulitis). Often untreated athletes' foot can be the source of recurring infection in the legs so this is really an important thing to pay attention to.

There are very good over the counter agents to treat this. Tenactin has been available since the 60's but it is much less effective than Clotrimazole or Miconazole which can be used to treat the fungus (70-80% effective). When these agents fail, Lamisil (terbinafine) is about 90% effective.

The fungus can also involve the nails and the plantar skin of the feet. If it involves the plantar skin, you will see a white fine white powdery scale that goes around the sides of the feet. The involvement around the sides of the feet with a fine red line at the margin is often called a moccasin change to reflect the area usually covered by a moccasin. The fungal infection can also involve the nail which results in streaks starting distally. Nail fungus often starts asymetrically and then becomes symmetrical. With time the whole nail becomes thick and sometimes even destroyed.

Once you have nail involvement then you need a culture because nails can be abnormal simply with lymphedema by itself. Unless there is a culture which shows fungal filaments and/or the growth of the fungus, you should not use oral anti-fungal agents to treat nail abnormalities.

You should make sure your physician takes a culture before taking oral Lamisil which may be the preferred drug for fungal infections of the nail. The health care professional has to check that there are no other drugs you are taking that might interact or change its effectiveness. Your doctor should probably do base line liver test although Lamisil only effects 1 in 10,000 people in terms of liver function abnormalities.

Topical creams are safe and very few people react to them. Persons with lymphedema and anybody with chronic leg problems and ulcers should avoid substances that could cause allergies. We cause allergies in 50% to 70% of people with some products. The topical antibacterial Neomicin should be avoided which also cross sensitizes you and wipes out intravenous Gentamicin and a lot of very important systemic agents.

Maintaining the skin moisture balance

Two things can be done to keeping the moisture balance in the skin. The stratum corneum (top layer of the skin) normally has about a 10% moisture content when it dips below 10%, you start to get dryness and flakes. Next you start to get the cracks and of course, the cracks or fissures, particularly in people with lymphedema, can be the areas of source of entry for the infection.

Dry skin should be monitored and watched very very carefully. In order to treat the cracks and fissures we can either lubricate, which is like putting vaseline or something oily on the surface and preventing insensible water losses. Alternatively we can put chemicals on the surface of the skin that actually bind water - and the two important ones are urea or lactic acid. They keep the stratum corneum moisture content for above 10%. Some of these include: Uremol, Dermol therapy, Lachydrin lotion and Dermalac cream. The most important time to apply these is after bathing, padding off excess moisture and applying the cream while damp.

If you dry a wound/open skin sore out you get a California raisin. A scab does not promote cellular growth and healing. So that is why we look at moist interactive dressings. These include calcium alginates absorb a fair bit and also help with bleeding. Hydrogels and hydrocolloids are relatively neutral and for protection we use absorbant foams. Povidone-iodine, acetic acid, hydrogen peroxide and or Dakin's solution (sodium hypochlorite) should not be used to treat healing chronic wounds.

Patients should avoid any agent that contains lanolin, which is a low sensitizer in normal people. It is a moderate sensitizer in people with asthma, hay fever and/or eczema and it is a high sensitizer for people with chronic leg problems. Over the counter products such as Keri Lotion act as lubricants but you have to be careful that they don't contain perfumes, which are another common sensitizer. Another major skin allergen is bacitracin which in found in Polysporin ointment but not polysporin cream. It often results in contact dermatitis. I don't recommend Neosporin because it has neomycin in it and neomycin is a common allergen.

Unfortunately in Canada there is no requirement to list ingredients in these products but it is compulsory in the United States. Many manufacturers voluntarily put it on their label but not all. Patients need to be informed consumers when buying topical over the counter pharmaceuticals.

Home remedies

Some patients use home remedies to reduce costs. Some are more effective than others. No product should be used without the knowledge and support of your doctor or specialist.

Bleach: Bleach is sodium hypochlorite. It's fine for your tabletop and your kitchen because it's a sanitizer. It's far too harsh and should not be used on skin since it can cause areas of breakdown.

Crisco: Crisco is an excellent lubricant, which has been used by dermatologists for very sensitive areas of the body. It has not shown any major complications as far as I am aware. Of home made remedies, this a better one.

Honey: Honey, of a commercial grade, can contain a certain number of bacteria that an individual could introduce into a wound including "botulism". The honey that has been shown to be beneficial against some resistant bacteria is predominantly produced from the Manuka plant, which is native to New Zealand, and that is the Manuka honey. This product is not currently widely available in Canada.

The problem with the honey is that it really doesn't perform autolytic debridement (clean the wound), it doesn't maintain moisture balance and it may only superficially address the bacterial balance - it does not eliminate it, it just reduces their number. We have agents that do a far better job in preparing the wound than honey.

Tea tree oil: Tea tree oil is something that may have some anti-bacterial and anti-fungal properties, but it is relatively expensive and can occasionally be an allergen. It has not really shown to address the other components in preparing the wound bed that we would like it to do.

Salt water: Salt water is simply saline. If you want to make your own salt water, that is fine as long as you don't dry the wound out. The new modern dressings really do better now. But you can make your own salt water by putting a teaspoon of salt in 8 ounces of water and micro waving it or boiling it but you have to remember that since the volume decreases with boiling it might be better to put your salt in after you boil it.

Baking soda: Baking soda is something that you can use to clean clothing and surfaces - but it is not recommended for the treatment of wounds. It tends to be slightly alkaline which promotes bacterial growth in chronic wounds which can delay healing, and it stings and burns. It would be better to use dilute vinegar which is more effective, but also often stings or burns.

Menstrual/bladder pads or diaper material as dressings: Menstrual/bladder pads or diaper material can be used as dressings on wounds - but individuals should look at some of the newer products out there before they use them. Non-sterile dressings can be bought in bulk at home health store or through a medical supplier reducing costs.

All chronic wounds contain bacteria. That bacteria is usually there as a contaminant or as a colonized bacteria that don't cause the wound any harm. When you go to buy gauze pads you don't need to buy the individual sterile ones, you can buy the bulk clean ones. The only exception is for somebody who is immune compromised through, for example, breast cancer operations, chemotherapy or radiotherapy treatment. In these situations sterile dressings are recommended.

Appropriate use of antibiotics

There is a use and abuse of antibiotics. If there is a definite infection - then we have to use systemic antibiotics. If we don't use antibiotics, the infection can cause damage to the tissue which can make the lymphedema worse.

There are antibiotics that we use, long term in acne, that are equally beneficial in lymphedema because these antibiotics also contain anti-inflammatory actions. The anti-inflammatory actions may help us in terms of preventing recurrent infections. Repeat infection cause even more damage to the lymphatics and more selling in the long term. If an individual has had two or three episodes of cellulitis in the past, using these long term - antibiotics and sometimes rotating them - is often useful. The drugs I am talking about are tetracyclines, trimethoprin and clindamycin, erythromycins (Note: erythromycin has recently been linked to heart attacks when it reacts with the two heart medications: diltiazem and verapamil).

In selected situations we may use Bactroban which is very good for Methicillin Resistant Staphylococcus Aureus (MRSA - resistant pathogens/bacteria). But as soon as we get a lot of swelling, redness, tenderness around a wound and pain, and especially if it probes to bone, then that requires oral or intravenous antibiotics and we're really looking at systemic agents to control infections. If there is an increased discharge and foul odour, antibiotics have to be used intermittently.

With pseudomonad bacteria, which can be common in people with lymphedema, we take a four-pronged approach: dilute white vinegar 1:5 or 1:10; topical agents such as silver sulfadiazine. The third step to use is oral agents such as ciprofloxicin. And when that fails we have to go to intravenous antibiotics.

Future directions

We will likely have more biological agents to treat wounds more effectively in persons with lymphedema and we may be able to find what is missing in a chronic wound and what treatments will stimulate it to heal. This may be a way to deliver anti-bacterial agents.

Unfortunately it is going to take a long time to treat wounds that way. In the mean time we are going to have to develop better health care systems which offer improved diagnosis and treatment in this area. And access to the expert clinics to ensure that intervention for these problems occurs at an earlier stage.

International Interdisciplinary Wound Care Course

The University of Toronto's Continuing Education Office of the Department of Medicine offers the IIWCC as a formal certificate course in wound care.
Contact them at: International Interdisciplinary Wound Care Course
Attention: Sandra Gauci
Administrative Assistant to Dr. Gary Sibbald
Women's College Hospital
76 Grenville St.
10th Floor, Room 1021
Toronto, Ontario
M5S 1B2
Phone: (416) 323-6400 x 4608
Fax: (416) 323-6215
email: inter.wcc@utoronto.ca