Patients with obesity are at risk for conditions including lymphedema and cellulitis. With an eye on providing appropriate access to accommodative care, this author details pertinent diagnostic and treatment considerations.
Nearly 1 in 3 Americans is the U.S. is overweight or has obesity. A number of comorbid conditions are associated with excess adiposity. Conditions of the lymphatic system affect a disproportionate number of individuals with obesity.
Lymphedema is described herein, including anatomic and physiologic characteristics, risk factors, and wound implications. The relationship among lymphedema, obesity, cellulitis, and massive localized lymphedema is explored. Access to size-appropriate care, including pharmacotherapeutic differences, is discussed.
What You Should Know About Lymphedema
Lymphedema, which is considered a disorder of the lymphatic system, affects more than 3 million Americans.1 The prevalence of lymphedema among people with morbid obesity is significant, especially among those with a body mass index (BMI) in the upper ranges.
From an anatomic perspective, the lymphatic system is comprised of lymphatic vessels or channels located just beneath the skin surface. When working properly, lymphatic vessels move fluid away from the tissues. Waste products, bacteria, and large protein molecules are collected. This composes the lymphatic fluid and is carried to the nodes where waste products are degraded and eliminated. The protein rich fluid that remains is returned back into the circulation.
Wound care professionals are often faced with patients whose lymphatic system fails to function properly. Figure 1 illustrates a person with obesity and lymphatic disruption. The abnormal accumulation of lymphatic fluid occurs when the lymphatic channels are disrupted. This disruption can be due to local trauma, radiation or surgery. Patients become symptomatic when the abnormal accumulation of protein rich fluid begins to collect in the interstitial tissue.
In the case of the person with morbid obesity, large fatty deposits can compress the lymphatic channels, creating either a mechanical disruption or complete obstruction. When the disruption/obstruction becomes profound, the lymphatic fluid exceeds transport capacity, and lymphedema occurs, as illustrated in Figure 2. This is most often seen in the arms and legs; however, in the presence of morbid obesity this swelling can occur over the abdomen, hips and buttock areas.
The World Health Organization estimates nearly 250 million people worldwide are affected by lymphedema. The primary cause, from a global perspective, is the mosquito-borne microfilariae parasitic infection found largely in the tropical regions of the world. However, in industrialized countries such as the USA, the etiology of lymphedema is more closely associated with surgery for cancer. For instance, women who have undergone surgery for breast cancer and men who have undergone surgery for prostate surgery often develop lymphedema in the arms and legs, respectively. In fact, 50 to 70% of women who have axillary node dissections will develop lymphedema in the affected arm. Studied to a lesser extent is the relationship among morbid obesity, body maldistribution and lymphedema.
In addition to swelling and discomfort, lymphedema influences both the formation of wounds and delays in healing. For instance, left unchecked, excess protein-rich fluid will cause the lymphatic channels to increase in size and numbers. This leads to decreased oxygenation in the tissue. This tissue hypoxia provides a culture medium for bacterial growth within the tissues. An increased bacterial load contributes to lymphangitis. As this condition progresses, the lymphatic fluid continues to accumulate and leads to swelling and fibrotic tissue. Each of these factors contribute to wound formation and delays in healing.
The Link Among Obesity, Lymphedema, and Cellulitis
Obesity stresses the delicate lymphatic vessels and serves as a significant risk factor in lymphedema. If left untreated, obesity-related lymphedema will lead to tissue breakdown, limited motion, and recurrent cellulitis. In fact, lymphedema may be precipitated or made worse by cellulitis. To that end, a conversation pertaining to cellulitis is tantamount to lymphedema. Figure 3 illustrates abdominal obesity, cellulitis and lymphatic changes.
Most wound care professionals recognize that cellulitis is an infection of the dermis and subcutaneous tissue and is the source organism is frequently Streptococcus or Staphylococcus. Clinicians are taught that cellulitis is characterized by warmth, swelling, redness, and advancing borders. Patients clinically may also present with an elevated body temperature and elevated white blood cell count. Cellulitis may develop in seemingly healthy skin, but usually develops in the presence of a break in the skin; however, frequently the break may not be recognized.
Hygiene, friction, and the inability to examine the skin place the person at risk for cellulitus. An individual with obesity may not have the ability to view all areas of the body, especially those areas between folds. Cellulitis among the high-risk patient, such as the person with excess adiposity, may progress to local tissue ischemia and systemic infection. Some patients report blistering and deep purple color changes in otherwise intact skin (Figure 4). These skin changes often deteriorate into a full-thickness injury. Therefore, the extent of the injury can range from acute erythema, with or without blisters, to extensive epidermal necrosis.
Cellulitis is a common condition associated with lymphedema because of changes in the skin function. The skin’s acid film of protection is destroyed in edematous or damaged tissue and the immunity of the skin is threatened. In the presence of obesity, the adipose tissue is thicker in the lower trunk (abdomen, hips, and buttocks). When ulcerations develop, they can be very difficult to treat. Itching and soreness are not unusual. Symptoms are often disregarded until pain, fever, and swelling make intervention necessary. Early, timely access to care is essential to prevent extensive tissue destruction.
Issues With Access to Health Care for Obese Patients
The prevalence of obesity is increasing among all patient populations; however, in their attitudes, equipment and common practices, health care systems are seldom prepared to accommodate the rising number of patients with obesity. Difficulties in accommodation range from scales, exam tables, or diagnostic tools that are not built to wide enough or with reasonable weight limits. Pharmacotherapeutics are seldom calibrated for the individual with excess adiposity.
Patients, irrespective of setting, should be encouraged to access care in a timely and appropriate manner. Early assessment and intervention of cellulitis or other skin changes are imperative, as these conditions will aggravate lymphedema and other lower leg or lower trunk skin issues. However, patients often delay care as long as possible because of past experience when a facility failed to accommodate the person’s weight or weight distribution. This failure to accommodate predictably leads to embarrassment, ultimately leading to a situation in which the patient delays access to care. A number of authors suggest preplanning for care, which includes size-appropriate equipment, is an essential first step.2
However, equipment alone is not sufficient to prevent the costly, predictable complications that can occur in a clinic setting. A comprehensive, interdisciplinary approach is necessary. Providers in the clinic must feel confident that a criteria-based protocol, which includes preplanning for examination and diagnostic equipment are in place. Training in the use of size-appropriate equipment, devices and services must be in place.
The criteria-based protocol in the outpatient clinic guides the clinician to tools and resources to maximize care. This protocol is simply preplanning based on specifically designated criteria and could specify resources such as size-appropriate equipment or clinical experts. The patient’s weight, BMI, body width, mobility level, and clinical condition serve as such criteria.3 Actual weight is a particularly useful criterion because breakage, failure to function properly, or patient or caregiver injury can occur if the weight limit of equipment is exceeded. Body width is described as the patient’s body at his or her widest point, which could be at the hips, the shoulders, across the belly when side-lying, or ankle-to-ankle. Furthermore, any clinical condition that interferes with mobility, such as pain, sedation, fear, or resistance to participating in care, places the patient at risk. Criteria-based protocols should be designed to meet the needs of the patient by ensuring access to resources, such as specialty equipment and clinical experts, in a timely, cost-effective manner.4
In the clinic setting, standard-sized equipment such as walkers, wheelchairs, commodes, bedside chairs, and recliners are inadequate. When selecting size-appropriate products for the clinic, consider the weight and width of the patient population. Family and visitors may be obese as well, so furniture in the examination room should have extended-capacity weight limits.
Gowns may not accommodate the patient’s body habitus. Discuss this with the clinic team to identify a dignified way to examine the patient respectfully. The use of size-appropriate identification bands or blood pressure cuffs need to be available. These are just a few items that not only contribute to patient comfort, safety and dignity, but ensure a more comprehensive examination and treatment process.
Treatment associated with lymphedema-related cellulitis is aimed at resolving the acute cellulitis and preventing recurrent episodes. Research suggests cellulitis is difficult to treat in the presence of lymphedema and obesity, and pharmacotherapeutics can be challenging. For instance, obesity alters pharmacokinetic parameters such as the volume of distribution, clearance, maximum and minimum drug concentrations. Few studies have been performed to assess what weight descriptors or overall method of creatinine clearance estimation is most accurate for obese patients.
Few studies have been performed in the obese populations for most antibacterial agents. Existing data for dosing antibacterials in obese people are limited by small sample sizes. Recent studies suggest that vancomycin initial doses should be calculated using total body weight with patient-specific dosing adjustments performed based on steady-state trough concentrations following the initial dose.
Aminoglycosides (amikacin, gentamicin, tobramycin) initial dosing should utilize ideal body weight plus a 40% excess body weight (total body weight-ideal body weight) correction factor with patient-specific adjustments based on peak and trough concentrations for subsequent doses. Other antimicrobial classes have varying alterations of pharmacokinetic parameters, necessitating evaluation of each individual agent. When dosing antibiotic agents, considerations should be given for severity of infection, infection site, infecting pathogen, local susceptibilities and patient-specific factors that affect the pharmacokinetics and pharmacodynamics of the medications.5
Delays or inadequate systemic treatment will alter the ultimate clinical outcome. A pharmacist who is knowledgeable and interested in care of the person who is obese is key to these decisions.
Insights on Massive Localized Lymphedema
The Lymphatic Education and Research Network (www.lymphaticnetwork.org) is a not-for-profit organization that offers extensive services, including support and resources to individuals and family members affected by lymphedema. Based on numerous stories related to readers, it is clear that massive localized lymphedema (MLL) can affect any part of the legs or trunk, is associated with a weeping, painful skin surface, cellulitis, sepsis and death. Figure 5 illustrates MLL. Many cases described on the Lymphatic Education and Research Network’s site are examples of individuals in varying stages of assessment and intervention. Individuals and family members relate difficulty in making the diagnosis of MLL.
Like many individuals featured on www.lymphaticnetwork.org, a diagnosis of MLL is likely made based on clinical history and presentation. Standard diagnostic studies can be challenging because of the person’s morbid obesity. Diagnostic tests such as magnetic resonance imaging (MRI) may be impossible due to the patient’s hip width, girth, lower leg dimensions or weight limit of the MRI equipment.6
Some clinics are equipped to perform complete decongestive physiotherapy (CDP), which is recommended.7 Surgical removal of the MLL collection may also be possible, but surgery can be technically difficult and not always advisable due to the risk of perioperative complications, including wound dehiscence.8,9 Considering the increasing number of individuals with MLL, the comorbidities and complexities of treating morbidly obese patients, and associated complications, wound care providers need a heightened awareness of this condition.
There is little literature to describe specific local skin and wound care necessary in the presence of MLL. However, an interdisciplinary team that includes a physician with experience in morbid obesity, the skin, and the lymphatics is essential to care.
As the numbers of individuals with obesity increase in numbers, health care providers best serve their patients in the clinic setting when they more fully understand the unique physical needs of the patient. Size-appropriate diagnostic tools, knowledge and equipment along with an understanding of the complexities of lymphedema are available to support providers in their effort to provide care in the clinic setting.
Susan Gallagher, PhD, RN, holds a master’s degree in nursing: advanced practice WOC nursing, a master’s degree in religion and social ethics, and a PhD in policy ethics. Dr. Gallagher is certified in bariatric nursing and is a Certified Safe Patient Handling Professional. She is the immediate Past President of the Association of Safe Patient Handling Professionals, and Associate Editor for Workplace Health and Safety (AAOHN). Dr. Gallagher is the author of more than 200 peer-reviewed articles, books and book chapters, including the ANA Implementation Guide to SPHM Standards, Bariatric SPHM and more.
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6. Gallagher SM. A Practical Guide to Bariatric Safe Patient Handling and Mobility: Improving Safety and Quality for the Patient of Size. Visioning Publishers: Sarasota, FL. 2015.
7. Fife C. Massive localized lymphedema, a disease unique to the morbidly obese: a case study. Ostomy Wound Manage. 2014 Jan;60(1):30-5.
8. Hou LG, Prabakaran A, Rajan R, et al. Concurrent bariatric surgery and surgical resection of massive localized lymphedema of the thigh. A case report. Ann Med Surg (Lond). 2019 Oct 11;47:53-56.
9. Machol JA 4th, Langenstroer P, Sanger JR. Surgical reduction of scrotal massive localized lymphedema (MLL) in obesity. J Plast Reconstr Aesthet Surg. 2014;67(12):1719-1725.