Bertsch and Erbacher (2018) have written a series of four articles to further our understanding in lipoedema – a condition lymphoedema therapists are encountering more frequently with the increased prevalence of obesity. In these articles, they have reviewed the literature on various aspects of lipoedema, highlighted controversy in the field and shared clinical vignette based on their clinical work with over 2000 patients at the Foldi Clinic – a European Specialist Center for Lymphology in Hinterzarten, Germany.
Lipoedema is often mistakenly used interchangeably with lipohyperthrophy. These are two separate conditions where by lipoedema is characterized by:
i) disproportionate distribution of adipose tissue in legs and/or arms, ii) subjective report of heaviness and /or soreness in affected limbs, iii) propensity to bruising and iv) fluctuating oedema. Lipohyperthrophy, however, refers to the irregularity of adiposity in lower limbs affecting primarily female without other clinical symptoms. Lipohyperthrophy does not always preceed lipoedema. To clinically differentiate lipoedema from lipothyperthrophy, “pinch test” – simultaneous pinching of an abdominal and thigh fat fold (lower leg or arm as applicable) has been suggested. If this test elicits pain the clinical diagnosis of lipoedema is confirmed. Oedema is not a diagnostic clinical feature for lipoedema.
Unlike lymphoedema, lipoedema is not progressive! The progressive nature observed in lipoedema patients is obesity as more than half (88% in the 2300 patients reported in this article series) of lipoedema patient population were obese with a body mass index (BMI) above 30kg/m². This highlights the need to address
the existence of three separate conditions when managing lipoedema patients namely: obesity, lipoedema and obesity-induced lymphoedema. In view of this, the use of BMI in conjunction with waist height ration will be a more comprehensive clinical assessment in lipoedema patients as the later provides a clearer reflection of body fat distribution.
Although manual lymphatic drainage has been recommended as part of management of lipoedema in various international lipoedema guidelines, no objective findings on imaging and histology to date has demonstrated the presence of oedema in lipoedema patients. So, the subjective report of symptoms improvement from lipoedema patient following MLD may perhaps be placebo effect.
Liposuction is a management approach favoured by lipoedema patients. However, a prospective randomized controlled trial by Hernanadez et al. (2011) have demonstrated that following surgical removal of adipose tissue, fat preferentially reaccumulated in the abdomen, hip and thigh within twelve months. Hence, a more concerted approach of addressing obesity with bariatric surgery after weight stabilization in lipoedema patients may be a better management option. As shown
by clinical data from Foldi clinic obesity program, following this approach generalized weight reduction (including lipoedema affected limbs) is experienced by lipoedema patients. This reduction when sustained in subsequent year(s), patients remain symptoms free i.e. less painful or pain free smaller legs and then lipoedema in remission.
In short, an effective lipoedema management begins with correct clinical diagnosis follow by a comprehensive management program to address commonly co-existing diseases: obesity and obesity induced lymphoedema together with patient somatic and psychological concerns.