James McGuire DPM, PT, CPed provides a review of the various pathologic entities which manifest in patients with chronic lymphedema and phlebolymphedema. Dr McGuire also gives a review of identifying factors for each entity while providing options for various treatment protocols both local and systemic.
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James McGuire, DPM, PT, CPed
Leonard Abrams Center for Advanced Wound Healing
Department of Podiatric Medicine and Orthopedics
Temple University School of Podiatric Medicine
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Male Speaker: Actually, I think we’ve seen the complications of this but we’re going to kind of go through some of them again. These are the same. Okay. Basically, just look at some of the pictures and see what you see. This is that kind of intense hemosiderosis around the ankle of lower extremity. Just a real darkening and pigmentation in the ankle area. You begin to see that lumpy bumpy skin around the ankle. What will happen is the ankle is one of these spots where like – you get a tremendous amount of inflammation in there from the edema. It will rapidly begin to scar and because it’s narrow and the pressures are very different there, it will scar down to the point where it can no longer expand with the edema, so you’ll see edema below the scarred ankle and then up into the calf, you’ll begin to see the expression of the, you know, sort of blockage of lymphatic fluid up in the upper leg and it has that wine bottle appearance where it’s very narrow at the ankle, very wide at the calf.
And I was talking to some of the stocking guys today and first of all we can’t get stockings for people without open wounds. So for goodness sake, order stockings just before the wounds heal. You know, if you’re not using stockings to treat the wound and there are some evidence that you can to some extent with some of the better systems that are out there now, that provide a little more consistent pressure. But if you’re doing wraps for wounds all the time, order stockings before the wound heals.
We forget to do this and then the patients healed and they can’t – they don’t qualify so get them when their wounds are open. If not, make a small pinhole wound. It’s called a biopsy, some micro biopsy, but it – you know, oh, they lost the results. But they will help.
Pain. You have to decide how you’re going to treat the pain, how you’re going to handle discomfort in your clinic whether it warrants an opioid or whether you have to use something else. And you can use a combination of things. You can use anti-inflammatories. You can use Neurontin or Lyrica but those all – both of those medicines create – you know, can worsen lower extremity edema. You can use steroids, topical steroids, you can use oral steroids, but there is a lot of controversy over whether you should use oral steroids in patients like this because it can result in an increase in edema particularly if you’re using it a lot and topical steroids overtime weaken the periwound and the skin around the wound and make it more likely that they’re going to break down at that site in the future. They also can result in a depigmentation or a loss of pigment in the area or at least a significant change in color and it may not be something you want to do.
Electrical stim or TENS is something that we don’t talk about very often but often pain can be managed effectively with some of these electrical stim stockings that are out there. There’s a company out there in the hall that I would – it’s the hall I was visiting today that has kind of a stocking style electrical stim electrode. And some of these electrical stim things produce a TENS effect which can be calming to the lower extremity and help with pain. We don’t often think about using e stim with this kind of wounds but – with this kind of edema problems and pain problems but it can be helpful.
Warmth to make it worse. In this particular wounds for venous insufficiency in phlebolymphedema soaking in warm tubs and applying warmth, that just stresses the system. So it’s just going to make it worse. So if anything just some cool water on the limb and wash cool, not wicked hot showers, no soaking in high hot tubs. Things like these are going to make kind of calm the limb down. Sometimes warmth seems like it’s going to be the right thing to do but it’s not. They’re not going to help you in the long run. You get sort of a rebound edema, rebound inflammation in any rotation that makes it worst afterwards and compression stockings for patients that can get them on. I noticed they had that little – what’s the little balloon that you used to put this – Doff N’ Donner. You know, that little dolphin. It used to be two dolphins in the symbol and that’s a very effective thing but you have to have patients that are going to buy some kind of donning mechanism because it’s extra so it’s not covered. It doesn’t come as part of the stocking. It often is $30 plus, $50 or whatever. I don’t know about you but I do not have a patient population that will buy anything that isn’t covered. No, thank you. But you need this.
No, thank you. If you’re not wearing your stockings, you can’t get them on. I know. I hate them. They’re too out. What do you fight with too tight? How do you fight too tight? You need 30 to 40. Now, one of the things that encouraged me one time is I got an edema where my mother – my mother-in-law has the same problem that I just – she just says, “Well, you don’t know what you’re talking about. I can’t get these things out. ” It’s my mother-in-law. So I got her to wear edema wear and it’s like compression. You know, it’s this funny open weave and I’m not recommending edema where it just happens to be the one that I have in our clinic.
And we were allowed – it’s just that tiny bit of compression significantly reduced the fluid buildup that she would get from sitting all day. You know, knees bent, legs down, that kind of fluid edema that just accumulates. So even though as she couldn’t get her stockings on that I had prescribed her – bought for her, paid for and hand it to her, she still would wear these other things.
So anything is better than nothing so just trying to move forward in compression like if you can’t wear 20, wear 15. If you can’t wear 15, wear 10. If you can’t wear 10, you know, find – pretty soon, you know, we’re going to be like outcomes are going to be important. How are you going to these patients to give you a good outcome? I can’t do it. Send them to another doctor. He gets a bad outcome, he sends him back to you. You change a diagnose code every time they come, it’s lymphedema – phlebolymphedema and current venous insufficiency, venous insufficiency with ulcer, venous insufficiency. We joke about it. That’s what I’m worried about. The system is going to encourage us to move people around with different diagnoses.
Okay, venous claudication sign is an interesting thing to look for. It’s secondary to longstanding venous hypertension. Ambulation will give you high limb pressures and that overwhelms the lymphatic system. It can’t get it out. The veins can’t get it out and starts to build up so there’s big high pressures during ambulation and the limb will hurt. So it’s going to be like claudication. They walk. As they’re walking, their limb gets more and more painful. It gets swollen, tight and it seems like they have claudication or, you know, arterial claudication. But what they’re really having is this venous claudication that the only thing that makes it better is when they elevate the limb and get their limbs up and get the edema down, the pain goes away. So it stays around. It’s not like when you stop walking it kind of gets better right away. It’s going to hang around until the edema goes down.
Once in a while, you’ll see patients complain that. This is venous dermatitis, chronic dermal disruption, ulceration. It looks like a little red flare but tons of little blisters. If it continues, you’ll get this and then you will get a secondary cellulitis – a true cellulitis. This is just inflammation associated with the protein build up under the skin and a massive inflammatory response. You got white blood cells coming down here. You’re releasing protease as you’re trying to break down to form proteins. Eventually, you’ll get RCBs out into the subcutaneous spaces then they’ll be attacked by the macrophages. They leave behind hemosiderin that causes more of a protein inflammatory reaction in the subcutaneous phases and it will eventually result in a breakdown of the skin then you can get bacteria in there of different kinds. It’s usually a strep or staph and it’ll become very, very painful and have a true cellulitis that will respond to antibiotics. The interesting thing is occasionally this will respond just to low dose doxycycline. We tend to use a little – we’re going to have a doxycycline resistance pretty soon but you use low dose doxycycline and it will go down.
Female Speaker: So like 50 milligrams?
Male Speaker: Yeah. There’s a 25. I’ve heard that 25 a day is adequate but we just give them 100. You use a subclinical dose for the bacteria. If there’s bacteria, that’s not going to work. But it reduces vasculitis slightly.
Keflex has a slight anti-vasculitic trait to it too but not anywhere near what – doxy has been used pretty consistently. They used to use Trentel, Trentel you can’t get anymore, you know, pentoxifylline works for this kind of thing too off the market. What did I do that one time? I was just yelling at it or, you know, I ignored it. Be like my wife, it will respond as soon as I don’t pay attention. Nancy would kill me. This is ankle flare. Hemosiderosis, we went through the whole process.
That’s a pyoderma. Somebody asked me, how do you diagnose a pyoderma. It’s really kind of diagnosis of exclusion. You exclude other things that might be causing this that has a certain clinical appearance. They always say if you’ve seen one, you kind of know it. You begin to get a feel for what it looks like. It’s that bluish discoloration in the periwound. Sometimes a bluish, reddish kind of puffy based, lots of puffy granulations tissue in there, lots of white blood cells accumulating in and around there, a lot of – just sort of massive inflammatory reaction. You’ll see what’s called path rigid developed. If you do any kind of steroid injection around or they do a biopsy, the puncture site or the biopsy site will produce a large ulcer. We did – this particular wound we did four little biopsies here and there and every one of them had a nickel size ulcer developed at the biopsy site. So we immediately know it’s that. Treatment for that is very different, anti-inflammatory steroids but then it’s also demarked and some of the anticancer medications are very helpful.
IV administration of these medications will help to restore this. It’s takes a very long time. We had one young woman who had a BK amputation just to get rid of it because it would not – just nothing worked. Lipodermatosclerosis can be early, very early, changes that progress to some that are fairly significant. If it scars up a great deal, you see this inverted wine bottle and lots of skin changes, lots of scaling, lots of itchiness of the skin. They need a lot of emollients.
We viewed – what do you feel about oil lanolin-based things? Any lanolin – lanolin can be a little allergen to – yeah, how do you know until you try it? But – yeah. Yeah. Okay. Because I tend to use the olive oil based or a coconut oil and then here’s another one, shea butter. Shea butter is a nice – it’s kind of a natural substance too and people respond very positively to that. Okay. Yeah. I’ll give it a sound. Well, that’s really funny, I didn’t touch a button that time. That was really weird. Ulceration, we see where they occur, mostly in the gator area, medial or lateral. They can be up or down the leg, anywhere proximal to there down. They can be circumferential. They can be, you know, significantly larger and encompass almost all of the foot.
We have one lady that gets – every time she gets it, it just always spreads all the way around like it never seems to stop. This is a very large anterior leg ulcer. This is a tiny piece of normal skin on island of heaven in the center of hell and I never understood why that – why did that not break down. It’s got like a little capillary area like loop that goes up to that skin that’s provide – it never broke down. That was the nicest of the healing process that just got larger and larger over time and that’s one that we treated with e stim because it wouldn’t let me put any compression.
You know, what do you do with patients that come to you and they have this big leg ulcers and they won’t let you compress it at all? Do you kick them out? You’re going to have to want to have a good – you got to have to have good outcomes. If you don’t get rid of them, if you’re not going to follow instructions, we’re getting rid of you so that you get rid of them. But then they all put it in our clinic because we don’t get rid of anybody. I have a solemn oath to try to make you better and keep going, don’t stop. That ulcer is – that slide is 2010 I think about and it’s there today. And what does she always say to me? No compression. No stockings. No compression. Now, it never got bigger, it never got smaller. It does occasionally get bio load. It get worse. You see that’s epithelial. Is that the edge? That’s during one of its good times. It won’t and it – biopsy is normal. Venous ulceration, yes.
Male Speaker: [Indecipherable] [0:14:33].
Male Speaker: Every two weeks. And then sometimes every four if she’s getting into a period where it looks like the inflammation is going down. She doesn’t tolerate oral steroid. She doesn’t like topical steroids. She doesn’t like any cleansers on it. It burns. I can’t take any compression. It just she’s living with a chronic wound. Yeah. Yeah. I love you. Now, I need to find someone who does manual infringe in my community who is open and can receive a new patient sometime and that – although there’s no hurry with this one.
So we could get – I’ll try that. You know, I really will. I’ll try – I hadn’t thought of that for that little condition but maybe that will help her.
Female Speaker: Can you repeat what you just said –
Male Speaker: Manual limb drainage. Get her in for lymphatic program. Yeah, she’s going to go through that. So these are what the wounds looks like, scaling [indecipherable] [0:15:28] we’ve been staining. Pain varies greatly. We already went through that. Shower our regular margins, you know, just nasty little looking wounds. These are all nice, healthy, beautiful granular beds that often just sit there for a while. They don’t epithelialize. But when they do, they start very slowly from the margins and then it takes a long time. You have new patient. Patients have to be consistent with compression and you have to use appropriate dressings and we talked about that too.
Is that maybe like some – discussion on dressings to use under these compression wraps like what do you do because a lot of them are based on having that vapor – high vapor transmission off the surface but they’re under a wrap so they can’t do that.
Atrophie blanche, ivory white skin and areas of scarring where those previous ulceration, not the wound obviously but the little dots, sausage toast, got this off the internet and guy has a blog, ronsrants.wordpress com and a lymphedema and compression not a good mix. Probably right. Yeah, I talk about this guy because he’s like going on and on about take – trying to compress some of it where it gets any better and he’s in this state right now. Ron.
I was reading his blog for a while. It’s very interesting to read a blog from a patient who’s having – not getting response and these clinicians are not listening to him and he’s just off on his own now and he’s doing in taking care of this on his own. Yeah, he’s doing a good job. Well, that picture was actually after he received compression. He ripped that off, the picture.
Acute and chronic cellulitis is kind of like afterwards. It’s actually not a good cellulitis picture but this is lymphedema rubra which is – it looks – it’s like a vasculitic inflammatory process from a buildup of fluid and the subcutaneous tissues. It leaves a little damp. It pits. It’s got that nice soft, red kind of those pinky red hue to it. It’s warm to touch. It’s usually not painful, but it’s real soft edema that begins to develop on the surface of somebody and it might start with the fact that they’re sitting a lot and edema just starts to buildup in the limb then it gets that redness around the limb. But this will progress very rapidly to inflammatory response and skin changes and a brawny edema if it’s allowed to kind of continue to be there and it’s not cellulitis.
And then PAM, talk a little bit about PAM. We’ll talk a little bit of 6plifestyle and social complications. But, I mean, these people all – they’re all – they smell horrible. I haven’t talked about that at all, but they really have very, very bad odor. The reason there’s a lot of lymphedema therapist like to work in the upper extremity, there are women that got into this treating breast cancer patients and there’s a whole lot of good things that come back up out of that but when you get down to lower extremity it smells awful. It’s very difficult to take care of. Patients are very heavy and hard to – they’re hard to manage. And their family rejects them. In the clinic, they’re the one – I can tell they’re the ones sitting all by themselves with nobody at their table, you know.
My former – poor former student over there all by herself and nobody will sit near them because they smell so bad. They get very angry. Really terrible body image. They don’t think of themselves. They don’t see much reasons to do the things that we’re asking them to do because they really don’t care. They’ve kind of lost it. And some of them may even think about suicide. So when you see – you sit with these people and tell them to get the help that they need, get the family support, the support that they need. They need to talk to therapist. They need to talk to psychiatrist every now and then that just help them get through it. It’s just a difficult process. That was –
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