According to statistics approximately up to 300,000 Australians will experience lymphoedema at any given time. Early detection is associated with improved outcomes. Accessing conservative oedema management for the condition is important to prevent degeneration that can result in decreased quality of life including loss of mobility and skin problems.
There is a link between skin health, chronic skin problems, wounds, infections, and the load this can have on the lymphatic system and so as skin health professionals, we need to be aware and respectful of the load we place on this system over time. Dermal health professionals play a role in educating those who may be at risk of lymphatic dysfunction as well as early detection. In our clinical settings, we can have clients presenting with early signs of chronic oedema.
The skin (integumentary system) and Lymphatic system are inextricably linked. Together they work to provide immune functions and protect against the outside world. When the skin is intact, it reduces the load on the lymphatic system to provide this defence. When the skin barrier is compromised this will result in inflammation and the lymphatic system having to work harder. This increase in load is due to the lymphatic system attempting to resolve inflammation by removing the fluid and working to neutralise any pathogens and other substances that could damage the body. Significant oedema in the short term, may cause the skin to stretch, compromising the barrier. When oedema has been present for a long period, inflammation in the skin can result in tissue changes including fibrosis, thickening and other dermatoses such as fungal infections, xerosis (dry skin), fissures and dermatitis.
Dermal Clinicians - Working in the Lymphoedema Space
Contributors (left to right)
Genevieve Topolov - Dermal Clinician - Toowoomba Dermal & Oedema Clinic
Diane Koksal - Dermal Clinician - Restore Cosmetic Tattooing
Alexandra Collios - Dermal Clinician - Victoria University (Clinical Educator)
As skin health professionals commonly working in clinical settings where we may see clients with early signs of lymphatic dysfunction we can educate our clients on risk factors that can negatively impact their lymphatic health. In this edition of the Lymphoedema Series, we are meeting some Dermal Clinicians who have expanded their scope or practice through further education to work in the Lymphoedema space to assist those experiencing chronic oedema with therapies to assist with skin health and conservative oedema management. We asked them a few questions to understand what inspired them to move into this area of specialisation and what they had to do to expand their scope of practice.
Can you tell us a little about what led you to work with people experiencing lymphoedema or chronic oedema?
My first exposure to the lymphatic system & associated dysfunction, disorders, conditions & chronic oedema, was as a student studying for a Bachelor of Dermal Sciences. This included industry placements in a lymphoedema clinic & in an aged care facility where I observed the impact of these conditions, particularly the reduced quality of life (QOL) & psychosocial effects on the patient. This led to my role as a Clinical Educator at VU where I teach in the Lymph & Adipose Unit & as a Clinical Supervisor in the VU Dermal Clinic.
(Alex Collios)
Learning about lymphoedema and lipoedema during my degree was the first time I saw how much dermal clinicians could contribute to managing oedema and lipoedema. When seeing clients with lymphoedema and lipoedema, it became clear to me that the technologies we specialise in and utilise have a role in improving the quality of life of clients with these conditions. I made industry connections which led to my realisation that offering oedema services could help bridge the large gap that currently exists in specialised oedema care.
(Genevieve Topolov)
When I finished my degree I had a position with a plastic surgeon who performed breast reconstruction on breast cancer patients. When they had finished their surgeries I would see the patients for post-operative micropigmentation (Areola and nipple tattooing). During my appointments with these patients, I noticed that some patients had oedema in their arms (secondary lymphoedema). Many of these patients didn’t know they had lymphoedema as very little education was provided to them about it. They are left with aching arms, experiencing heaviness discomfort and self conscious as one arm is bigger than the other. May expressed to me that they had survived cancer but were now left with this to manage long term! I would provide manual lymphatic drainage for them. This became of interest to me. Over the years the awareness of lymphoedema has increased and providing the patients with information to watch out for the signs of it developing is important. As well as supporting them with strategies post-surgery to assist with managing oedema and detecting problems early including getting into prophylactic garments and performing gentle exercises.
(Diane Koksal)
Tell us why skin care and skin health is important for those with lymphoedema from your perspective?
Lymphoedema is a chronic inflammatory condition of the lymphatic system & treatment involves a long-term management plan. Skincare, compression, movement and manual lymphatic drainage are the four cornerstones of self-management for lymphoedema.
Maintaining/improving barrier integrity and assisting with this through skin care is key to reducing portals of entry of opportunistic pathogens & preventing secondary infections which could result in further inflammation & increase the lymphatic load on an already compromised Lymphatic system.
(Alex Collios)'
Recovering skin health is vital in managing skin symptoms and tissue deterioration which leaves the skin prone to injuries, hard-to-heal wounds, infections, pain, discomfort and symptoms such as lymphorrhoea. When looking at a limb with skin changes, particularly when there is a vascular causation or involvement, skin care products and treatments are a very important (yet often overlooked) pillar of lymphoedema care. Dermatological skincare products can improve skin recovery and effectively address lymphoedema-related symptoms, well beyond what a benign moisturiser can achieve. Therapies including compression, low-level laser therapy and manual lymphatic decongestion, help prevent lymphoedema from progressing to cause skin changes, but also become vital to recovering skin health and restoring quality of life to clients who do develop these problematic skin changes.
(Genevieve Topalov)
Skin health and care are so important, In my experience, I encounter tired patients who are over it but they unfortunately come to realise skincare and health are important to prioritise otherwise the management of lymphoedema is a lot harder and more painful for them.
A compromised skin barrier can lead these patients to cellulitis which I’ve seen happen, unfortunately. Self-care is important too by massaging the area to keep the tissue soft and preventing fibrosis.
(Diane Koksal)
What further education & training is required to work in this area?
Dermal clinicians can provide services to assist with the conservative management of both lymphoedema and lipoedema, including manual lymphatic decongestion, skin care products and low-level laser therapy (LLLT)/medical grade LED. However, if planning to see clients with complex oedema, or peri-operatively for lipoedema, it's important to complete a lymphoedema course accredited by the Australasian Lymphology Association (ALA). As dermal clinicians, it is important to look at what each course offers in terms of addressing both lymphoedema and lipoedema including light-based therapies and skincare. It is helpful to look at additional courses the training provider has, such as advanced compression garment courses for complex oedema, seminars with experts in lymphoedema and lipoedema, and ongoing professional development opportunities.
To become an accredited lymphoedema therapist with the ALA, an accredited course needs to be completed. However, as dermal clinicians and members of the Australian Society of Dermal, Clincians it is not necessary to become an accredited therapist to offer conservative therapies within our scope of practice. Compression and remedial lymphatic decongestion are also covered under the ASDC's recommended insurance policy for dermal clinicians.
(Genevieve Topolov)
I completed additional training with The Oedema Institute Australia who offer a Lymphoedema Accreditation Course. There are other courses and accredited providers around Australia. You can find these on the ALA website under accredited training providers. These are evidence-based programs with a focus on lymph anatomy, lymphoedema, lipedema & oedema, vascular insufficiency, management & treatment planning. The Oedema Institute also offers workshops, seminars & webinars on compression garments & wraps, manual lymphatic drainage (MLD) & liposuction (medical education/ guest speakers).
(Alex Collios).
New research and information is constantly available and evolving. For example with lymphatic drainage, it used to be taught to only use light pressure techniques however through advancing in real-time imaging we now know some areas or when there is fibrosis may need more pressure. If I didn’t go to workshops and seminars to update my knowledge, I would not have known this. Registering with associations is also important as networking and sharing of experiences helps significantly.
(Diane Koksal)
Tell us more about how you use your knowledge & expertise as a Dermal Clinician to assist those with Lymphoedema?
As a Dermal Clinician, we must work within our scope of practice & know when to refer our patient to an allied health professional if required. A Dermal clinician can work inter-professionally for a patient-centred approach for optimal outcomes. For example working in an integrated approach with other health professionals such as G.P., podiatrists, dieticians, vascular surgeons, psychologists, dermatologists, and physiotherapists.
Within our scope of practice and with appropriate training we can perform manual lymphatic drainage (MLD), low-level light therapy (LLLT), LED, 4-layer compression bandaging and kinesiotaping.
We can also educate our patients on skin health/barrier integrity including daily application of SPF & covering up with clothing & hats when outdoors to prevent an inflammatory response initiated due to extended UV exposure. Other advice and education we can provide include how to perform self-lymphatic drainage (SLD) techniques, deep breathing exercises, calf muscle pump exercises, and keeping up with gentle movement or exercise such as swimming, walking, and stretching.
(Alex Collios)
As a dermal clinician, I am uniquely positioned to draw on my knowledge of advanced skincare ingredients and tissue repair technologies, to apply in addition to standards of care for lymphoedema and lipoedema. This ultimately leads to more effective management, particularly of skin changes and effectively managing oedema. For example, I am currently managing a 92-year-old client with bilateral lower limb oedema, a complex medical history including heart failure, and tissue deterioration with lymph-filled vesicles on her lower legs. Her treatment plan takes into consideration the current symptoms, preventing skin injuries and prescribing treatments appropriate for her heart health. Her treatment plan includes Class I compression garments and donning/doffing aids designed to prevent skin injuries; LLLT for tissue repair and pain reduction, as well as skincare containing niacinamide, zinc gluconate and emollients to support the skin's recovery.
This is very different from the treatment plan for stage II lipoedema in a 30-year-old woman already adherent with compression therapy who is preparing for lipoedema extraction surgery. In this case, we are providing MLD with remedial techniques and LLLT to address adipose nodules and soften the tissue for surgical extraction. She is booked also for MLD and LLLT post-surgery to improve her recovery, and has had custom-made compression garments ordered for her post-surgery oedema management.
This huge diversity in cases means I am in constant liaison with surgical teams, garment manufacturers, doctors, and nursing teams and staying on top of updated guidelines and developments to ensure clients receive the best care, but also draw on my foundational training to critically assess what is most appropriate for my clients.
(Genevieve Topolov)
I use my skills to assess the skin and oedema progression when I see my lymphoedema patients. With my lymphoedema patients when I see them post op I also guide patients to feel around and teach them how to do SMLD. This can be so important as I’ve seen patients who haven't used strategies to manage their oedema and the tissue becomes so hard (fibrotic) which can have a snowball effect. The Fluid build-up becomes trapped and can not get through the fibrotic tissue then discolouration happens around the area. This further leads to more pain and discomfort, not to mention becoming more prone to infection. Showing how to use simple steps daily and supporting them to make these part of their life can have such a positive effect. It's also important to check in with them that they are using their compression garments and that they still fit too. It’s not just one thing that will help them it’s a Complete Decongestive Therapy (CDT) approach that will change these patients daily lives!
I have a beautiful patient who every time she comes back to Australia (resides in Malaysia) books in for MLD. She has told me she values the knowledge we provide, and respects what we do. This feedback was provided after our initial session, where I showed and provided her with some techniques she could do at home impacted her tremendously.
Another patient had fibrotic tissue months after her surgery so we provided her with some laser, LED and Massage and she was so happy and relieved! She had a lot more ability to move. Her pain and the sensation of pulling in her leg where she had the lipoedema and lymphoedema went away and provided her with more flexibility. She started moisturising daily and the integrity of her skin improved significantly.
(Diane Koksal)
What is one thing you think the Dermal Clinician should know or some advice that may inspire them to consider working in this area?
New findings from recent research on our lymphatic system & lymph anatomy are leaning towards new approaches to treatment, treatment planning & prevention for these conditions, so it’s an exciting time.
Through your knowledge from your undergraduate degrees, you will use your critical thinking to assess if this is within your scope of practice or if you need to refer this patient on & work collaboratively within an allied health professionals’ team.
Out in industry, you will often have this cohort of patients coming into your clinics & workplaces and they often have no idea that they have lymphoedema, lipedema or chronic oedema. They are only aware of the presenting symptoms of these disorders for Eg. “I have heavy legs”, “my leg feels tight & itchy”, “one of my legs is bigger than the other”, “I bruise easily, I always feel tender”. Your encounter will start them on their lymphoedema/ chronic oedema/ lipedema management journey to an improved QOL.
(Alex Collios)
My big concern going into business and offering oedema services was whether or not it would be economically sustainable to do so. The short answer is that it is. The longer answer is that I worked a lot with my investment partner to develop a fee structure and processes to ensure I can charge appropriately for my expertise and services.
There is a wealth of opportunities and a huge demand for oedema services. It can take some resilience and persistence to find them, but it is extremely rewarding and you can succeed in business doing this work.
(Genevieve Topolov)
You may think we can not do much for these patients, but a simple chat explaining to these patients the importance of self-care, looking after their skin showing them how applying a barrier cream and doing a light massage has substantial benefits. What you do can provide them with empowerment and hope!
(Diane Koksal)
Summary
We thank our dermal clinicians for sharing their knowledge and experiences. If you haven't considered working in the disability and health care space with your unique skill set and expertise it is a rewarding and impactful area to work. Forming professional networks through associations such as the Australian Society of Dermal Clinicians and the Australasian Lymphology Association will assist you to learn from others and keep up to date with education opportunities as well as guidelines for practice.
If you aren't a member you can join us today and learn more about all the ways and clinical settings in which we can work.
Further Reading and References
Borman, P. (2018). Lymphedema diagnosis, treatment, and follow-up from the view point of physical medicine and rehabilitation specialists. Turk J Phys Med Rehab, 64, 179-197. doi:10.5606/tfrd.2018.3539
Li, J., Zhao, Z., & Zhou, J., & Yu, S. (1996). A study of the three-dimensional organization of the human diaphragmatic lymphatic lacunae and lymphatic drainage units. Annals of Anatomy – Anatomischer Anzeiger, 178, 537-544. https//doi.org/10.1016/50940-9602(96)80113-0
Meharara, J. B., Radtke, J. A., Randolph, J. G., Wachter, T. B., Greenwel, P., Rovira, I. I., Galis, S. Z., & Muratoglu, C. S. (2023). The emerging importance of lymphatics in health and disease: an NIH workshop report. The journal of Clinical Investigation, 133(17). https://doi.org/10.1172/JCI171582
Nowicki, J., & Siviour, A. (2013). Best practice skin care management in lymphoedema. Wound Practice & Research. Journal of the Australian Wound Management Association, 21(2), 61-65.
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