Best Practice Guidelines: The Management of Lipoedema

Published by Wounds UK 2017

Lipoedema is a condition that can, in some cases, have a severe impact on quality of life. This is not only from its physical impact but as importantly its psychological impact. Its recognition is slowly improving especially as consumer organisations become developed.

It has been difficult for health professionals to obtain accurate information on assessment and management of this condition. The Best Practice Guidelines: The management of Lipoedema is a step forward in the right direction. As recognised by the authors of this document there is still much to learn about lipoedema however the development of these guidelines will provide health professionals with much needed guidance for the management of this, often difficult to treat, condition.

This article enables you to quickly view the sections included in the guidelines. The guidelines key points for each section have also been included.

Section 1: Epidemiology and pathophysiology of lipoedema

  • Prevalence
  • Cause
  • Enlargement of fat tissue – including an easy to understand flow chart
  • Development of oedema

Key points listed for this section:

  1. Lipoedema is under diagnosed and almost exclusively affects women.
  2. Although lipoedema is often misdiagnosed as simply being obesity, lipoedema and obesity can co-exist.
  3. Hormonal and genetic factors are likely to contribute to the adipose tissue enlargement characteristic of lipoedema.
  4. Patients with lipoedema may develop secondary lymphoedema (lipolymphoedema), which may be compounded if chronic venous insufficient is also present.

Section 2: Diagnosis and assessment

  • History and symptoms
  • Examination
  • Differential diagnosis
  • Investigations – laboratory tests, imaging investigations and hand held devices.
  • Classification and staging – including an excellent table with photos that explain each stage
  • Assessment. This includes degree and extent of adipose tissue enlargement, pain, mobility and gait, psychosocial, diet, skin and vascular and comorbidities.

Key points listed for this section:

  1. The diagnosis of lipoedema is made on clinical grounds: there are no diagnostic tests for the condition.
  2. Lipoedema is a condition that is distinct from lymphoedema.
  3. Lipoedema may have a significant impact on a patient’s physical and mental health and wellbeing.
  4. Patients with lipoedema generally report a history of bilateral symmetrical limb enlargement, with sparing of the hands and feet, which is not responsive to dieting. They may also report pain, sensitivity to touch and easy bruising, and a family history of similar tissue enlargement and shape disproportion.
  5. Affected areas of the body may be softer and cooler, with a texture that is dimpled or resembles a mattress.
  6. The presence of pitting oedema in affected areas indicates lipolymphoedema.
  7. Routine blood tests may be useful to exclude or identify other conditions.
  8. Imaging investigations are not used routinely.
  9. Further work is required to develop a classification/staging system for lipoedema that takes into account disease progression along with symptoms such as pain or restrictions to mobility.
  10. Holistic assessment should include the degree and extent of adipose tissue enlargement, presence and level of pain, mobility and gait, psychosocial assessment, dietary assessment, skin assessment, vascular assessment and assessment of any comorbidities.
  11. Psychosocial assessment is particularly important in people with lipoedema because of the long-term nature of the disease and the importance of self-management.

Section 3: Principles of Management

  • Principles of lipoedema. The holistic approach includes:
    • Facilitation and enhancement of the patient’s ability to self-care.
    • Managing symptoms.
    • Optimising health preventing disease progression.
  • Benefits of lipoedema management.

Key points listed for this section:

  1. A multidisciplinary approach to the management of lipoedema is necessary.
  2. Management aims to manage symptoms, to facilitate and enhance the patient’s ability to self-care and optimise health and to prevent disease progression.
  3. The main components of lipoedema management are: psychosocial support and education, healthy eating, weight management, physical activity, skin care, compression therapy and management of pain.

Section 4: Psychosocial support and self-care

Key points listed for this section:

  1. In common with other chronic conditions, psychosocial support underpins the management of lipoedema and is important in encouraging self-management and realistic expectations.
  2. Clinicians need to identify and help patients to deal with potential barriers to self-care.
  3. Mental health issues may affect carers as well as patients with lipoedema.

Section 5: Healthy eating and weight management

Key points listed for this section:

  1. Although attempts to lose weight may not have an impact on enlarged adipose tissue, preventing or reducing obesity in other parts of the body through healthy eating and physical activity will help to prevent deterioration in general health.
  2. There is no clinical evidence supporting the use of a particular diet. Patients should be encouraged to find a healthy, balanced diet that suits their needs and lifestyle.
  3. Patients with lipoedema should be encouraged to be physically active and undertake activities that suit their needs and lifestyle, while taking into account that some patients may have individual limitations.

Section 6: Skin care and protection

Key points listed for this section:

  1. Skin folds may be prone to fungal infections and should be washed and dried with care.
  2. Patients with lipolymphoedema are at increased risk of cellulitis.

Section 7: Compression therapy

  • Assessment and contraindications.
  • Types of compression therapy.
  • Compression garments and adjustable wraps (including a useful algorithm for compression selection).
  • Lipolymphoedema.
  • Measuring for and prescribing compression garments and adjustable wraps.
  • Intermittent pneumatic compression.

Key points listed for this section:

  1. Compression therapy is used in lipoedema to reduce pain and support tissues. In lipolymphoedema it is also used to reduce swelling due to oedema.
  2. Compression therapy does not reverse adipose tissue enlargement.
  3. Patients being considered for compression therapy should undergo arterial assessment to exclude peripheral arterial disease.
  4. Choice of compression therapy depends on a wide range of factors, including individual choice and ability to manage.
  5. The main type of compression therapy used in lipoedema is compression garments.
  6. Most ready-to-wear garments are circular knit, which produces a thinner fabric that may be more prone to cutting into tissues.
  7. Most custom-made garments are flat knit, which produces a thicker more rigid fabric. These garments may be more suitable if there is considerable limb distortion.
  8. Adjustable compression wraps may be useful for patients who find applying garments difficult or painful, and can be used alongside compression garments applied to other body areas.
  9. Multi-layer bandaging may be useful in patients with lipolymphoedema as an initial step to reduce oedema and/or pain to a level where garments become manageable.
  10. Measurement and fitting of compression garments should be undertaken by appropriately trained and competent clinicians.
  11. Garments generally need to be replaced every 6 months.
  12. Intermittent pneumatic compression (IPC) may be used as an adjunct to compression therapy in patients with lipolymphoedema.

Section 7: Other non-surgical approaches

  • Manual lymphatic drainage
  • Kinesiology taping
  • Other treatment modalities
    • Electrostatic massage therapy
    • Self-lymphatic drainage or dry skin brushing

Key points listed for this section:

  1. Manual lymphatic drainage (MLD) stimulates the activity of the lymphatic system and may be used in conjunction with compression therapy to reduce oedema and control symptoms such as pain in lipolymphoedema.
  2. Some patients with pure lipoedema find MLD helps to reduce pain and discomfort.
  3. Kinesiology taping may help to improve blood and lymph circulation and to stabilise and realign tissues and joints.

Section 8: Surgical management

Liposuction and bariatric surgery is discussed in this section.

Key points listed for this section:

  1. There is no evidence that liposuction cures lipoedema, but it may reduce limb bulk and so improve functioning and mobility.
  2. Patients should be advised to try at least 6-12 months’ non-surgical treatment before undergoing liposuction.
  3. Pre-operative counselling is important to ensure patients understand the non-curative nature of liposuction, the long often painful post-operative course, and the need for ongoing wear of compression therapy.
  4. Bariatric surgery may be indicated for some patients with lipoedema who are also obese.

Patient pathway

Appendix 2 includes a detailed easy to follow patient pathway algorithm for each stage of lipoedema.

Everyone who reads this document will take away something that will assist them in managing this condition more effectively.

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