The importance of skin health and integrity for those that suffer from acute, problematic and chronic swelling shouldn't be underestimated. In Part 1 of the Oedema Series we revise what causes swelling, when it becomes a problem and what your role is in identifying problematic swelling. In following posts we will focus on some of the emerging evidence in relation to understanding more about how swelling occurs and resolves, therapies for management and what this may mean for the Dermal Clinician and Therapist.
What causes swelling?
Swelling or its medical term Oedema is caused by an accumulation of fluid in the interstitial spaces between cells. This can happen within the body, for example pulmonary oedema (fluid in the lungs) and cerebral oedema (swelling of the brain). However in Dermal Science and Therapy we are concerned with the more common occurrence of oedema within the skin (peripheral oedema). The regulation, balance and movement of water and solutes within different compartments in the body relies on many different systems to maintain homeostatic function. These include neurological (nervous stimuli), renal (kidney), cardiovascular (heart and blood vessels), integumentary (skin) and the lymphatic system.
For most of us, swelling is something that we live with at some point or another. This may be due to an injury, medication we have been taking, pregnancy or perhaps even a surgery. Dermal Clinicians and Therapists know that swelling is an expected side effect of any treatment that causes inflammation in the skin. We even use that as a positive endpoint, as regeneration of the skin requires inflammation and associated swelling to allow much needed cells and co-factors for healing to get to the site.
However any swelling that is disproportionate, persists for an extended period of time, causes considerable discomfort or affects daily activities is cause for concern and further investigation. Swelling that occurs in the elderly, with medical conditions such as diabetes, cardiovascular disease and cancer should not be ignored.
When is swelling a problem?
Swelling is a normal and expected function of human healing. In response to tissue damage or injury, the body will have an inflammatory response. This results in vascular hyper permeability allowing for movement of cells and fluid to the area. This process facilitates immunological functions and repair or removal of damaged cells and tissues. Normal acute inflammation and swelling will usually peak at 3-7 days after the injury and then will slowly dissipate. How long this takes varies depending on how extensive the injury was, but usually within 4-12 weeks swelling will be markedly improved or gone altogether. Problematic oedema can be defined as acute oedema that is disproportionate and causing issues such as pain or discomfort, problems with movement and activities of daily living and causing risk to skin integrity. Whilst oedema is a normal part of healing, due to many factors it can negatively impact on optimal healing. Early management and support will improve wound repair, reduce risk of or degree of scarring, improve range of movement and prevent further complication in the future.
Chronic oedema is under recognised as a problem and under managed. Chronic oedema can be diagnosed medically when swelling has been present for more than three months. It is a multi-factorial condition, meaning that the condition is not often caused by one thing. It is the contribution of many factors over time. However, it is known that the lymphatic system is responsible for returning fluid from the interstitial spaces to the cardiovascular network. Therefore degeneration of this system and its ability to do this task is seen as being the resulting problem. Patients with chronic oedema will often say that there was a defining event where the problem made itself known. What they didn't realise is that they probably actually had sub-clinical oedema for many years before this. Chronic oedema may or may not be reversible depending on what is exacerbating the issue and how long it has been present. Risk factors that can result in chronic oedema at some point in a persons life include obesity, pregnancy, venous insufficiency, heart or kidney problems, medications that cause fluid retention, significant or ongoing injury and increasing age. Genetic predisposition may also play a role. Early identification of problematic and chronic oedema is important to ensure that the condition is managed to prevent further problems and degeneration.
Lymphoedema is a form of chronic oedema. However lymphoedema is caused by dysfunction or failure of the lymphatic system itself. Chronic oedema if present and unmanaged can develop into lymphoedema. However lymphoedema can also occur due to malformation or genetic predisposition to lymphatic dysfunction. As the lymphatic system is responsible for returning fluid to the cardiovascular network, when it is not working the fluid will not resolve on its own and the condition is not reversible. Early identification and management can prevent the condition from worsening or causing significant health problems. It is reported that 1 in 30 people globally suffer from lymphoedema, however this may not be accurate as most people only seek diagnosis when there is already significant swelling. Therefore mild forms may not be picked up in this data. In Australia, lymphoedema is mostly associated with cancer and its treatment, though it can be the result of many factors that can damage the lymphatic system. 1 in 5 woman with breast cancer and treatment will have to manage lymphoedema afterwards. In most cases this presents within the first 12 months of treatment. However it can occur at any stage afterward. Any cancer that results in removal of lymph nodes, radiation or chemotherapy increases the risk of developing lymphoedema. This includes melanoma which reports an incidence of 6-58% cases of lymphoedema, 18% incidence rate in gynaecological cancers and 25-66% for prostrate cancer.
The not so missing link: Skin, lymphatics and 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 both attempting to resolve inflammation by removing the fluid but also due to working to neutralise any pathogens and other substances that could damage the body. On the other hand, when there is significant oedema in the short term, this can result in stretching or even breaking of the skin barrier and damage to the skin including wounds. When oedema has been present for a long period of time, the 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.
Therefore we need to know that any skin that is not intact particularly for long periods of time, will result in chronic inflammation, oedema and ultimately is a risk for overloading the lymphatic system in time. Conversely providing simple management strategies to manage oedema and skin barrier can assist in improving the outcomes for those with swelling.
The role of the Dermal Clinician.
Skin and lymphatic wellbeing is definitely within the scope of Dermal Clinicians. They study as part of their Bachelor degree programs, anatomy and physiology of both the lymphatic and integumentary systems as well as its management in health and disease. The Dermal Clinician and Therapist also play a really important role in education of those that may be at risk of lymphatic dysfunction as well as early detection. In our clinical settings we often have clients presenting with early signs of vascular insufficiency (leg veins and capillaries), obesity, increasing age, planning surgical procedures and dermatological conditions that are associated with increasing lymphatic load. Therefore implementing assessment of lymphatic and skin health, as well as simple education and management strategies to assist with optimal lymphatic function, could play an important role in reducing the incidence and severity of lymphatic dysfunction.
In following posts we will explore the tools and techniques available to assess and manage skin health and lymphatic function.
References
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