Mrs. S is a 52 y.o. 5' 4" 220lbs Hispanic female with dark skin tones. Past medical history includes a history of 4 pregnancies with 3 vaginal deliveries, hypertension, chronic venous leg ulcers, and moderately well-controlled diabetes type II. She presents to your wound clinic with a recurrence of her right lower leg ulcer just above the medial ankle. You are the clinic wound care clinician, and this is the first time you have seen this client. Mrs. S. states she is not experiencing any pain, do not smoke, rarely uses alcohol, denies using other un-prescribed substances, and complains that she is tired of this ulcer reappearing every few months, she feels self-conscious with bandages on the lower legs all the time, and they fall down "a lot."
The medical record review shows routine labs conducted 3 months ago were mostly within normal limits with a hemoglobin A1c of 7.5 (a test that measures the level of hemoglobin A1c in the blood to determine the average blood sugar concentrations for the preceding two to three months). About 10 months ago, she also had a normal ABI (ankle-brachial index) of 0.8 to assess her arterial perfusion.
You move on to conduct a focused examination of the lower extremities. You remove ace wraps from both legs, which she says she applies daily. Although she has prescription compression stockings (30-40 mm hg, firm compression) which are about 10 months old, she says they "are all stretched out" as far as they will go (she admits to putting them in the washer and dryer sometimes more than once a week). You also remove a hydrocolloid dressing over the right leg wound; you note some swelling of both lower extremities, but the right lower extremity appears slightly more edematous than the left. Her dorsal and posterior tibial pulses are fairly strong (3+) bilaterally, and you note there is 2+ pitting in the right foot evidence when pressing on the dorsalis pedis pulse in the right foot (and 1+ noted in the left foot).
There is a shallow 2.5cm diameter ulcer with irregular margins over the medial right ankle above the malleolus, which you expected to see as it is consistent with a classic venous ulcer. Mrs. S. complains that it "itches" a lot around the lower edge of the wound, especially at night, and while there is slight maceration and very slight periwound redness that extends 0.5 cm from the inferior wound edge, the wound bed is pink, moist, and otherwise unremarkable.
You also notice something else. The toes of the right foot look like stacked inner tubes, and when you attempt to pinch the skin at the base of the 2nd toe, you are unable to do so; note that this is a positive Stemmers sign suggestive of a lymphedema component that has previously not been identified in the patient's chart. You continue your exam to gather more clinical clues.
Even though Mrs. S. has been wearing her stockings, both feet and lower legs are edematous, and the skin is taut. The dorsum of the right foot appears more "puffy" than the left, giving the contour of her foot a 'box-like' appearance- another indication of lymphedema. Although it is sometimes difficult to discern hemosiderin staining of the gaiter region in people with darker skin, you palpate this area and feel a woody non-compressible quality to the tissues that are also consistent with venous insufficiency. However, you continue palpating proximally and note that the calf areas are also firm or what is often described as 'fibrotic,' and this clue is suggestive of lymphedema. The thigh and inguinal areas are spared.
You ask Mrs. S. if she has ever heard of a 'lymphedema' diagnosis, and she says she has never heard of that before. You explain that longstanding venous insufficiency can be associated with secondary lymphedema, which can make it more difficult to manage but, once properly identified and treated, can end the cycle of re-ulceration or at least minimize recurrence.
You decide that this case could likely be managed in the clinic without referral to a lymphedema specialist since there is not one in the local area, and many will not treat while there is still an active wound. Nevertheless, you talk to Mrs. S about a potential future referral to a lymphedema therapist as an option, should it become necessary.
Since Mrs. S's lower extremity pulses are palpable and her ABI was 0.8, you anticipate compression can be applied at higher levels to reach therapeutic benefits and get the edema under better control while addressing the wound. Over the next few weeks, you evaluate the compression options and after talking to Mrs. S., decide to go with multilayer compression (absorptive contact/base layer, covered with a short stretch bandage and a more elastic top layer) on both legs, verifying the amount of compression at rest, standing and walking the first time it is applied (with a pressure monitor explicitly made for this purpose). Your goal is to reach pressures between 40 mm Hg and 60 mm Hg when walking at the strongest calf muscle contraction. You also evaluate Mrs. S's compression tolerance to ensure she has no discomfort from the compression at rest and her pulses are still palpable (and toenails have good capillary refill) when the legs are elevated and at rest with the bandages intact. You also choose a more breathable, antimicrobial fiber absorptive cover dressing over the wound before applying compression bandages. You schedule twice-weekly visits in your clinic to re-evaluate her progress for the first 2 weeks, with a goal of re-measuring her legs, ordering her new compression stockings every 6 months and giving Mrs. S. instructions to hand wash and air dry to maintain elasticity longer.
It is important to note that some insurance companies may not approve compression therapy on a non-ulcerated, contralateral extremity-so it is important to verify coverage limitations. If this limitation is present, make sure that the diagnosis of lymphedema is mentioned in the justification and refer to any progress made by the Lymphedema Treatment Act submitted to congress in March 2015 (visit source) to see if any states have adopted the stipulations mandating treatment for lymphedema including compression garments. Also, consider referral to a lymphedema therapist as an alternate avenue to initiate earlier in the treatment plan.
You encourage Mrs. S. to limit her salt intake, continue efforts with weight loss (maintaining adequate low-fat protein intake), and consider starting a walking exercise program. You proceed to monitor progress with evidence-based wound care for the open ulcer. Serial circumferential measurements of both lower extremities are taken at each visit along with measurements of the wound(s), and Mrs. S. is delighted to see the measurements steadily decrease.
Finally, the ulcer is closed, and you start the next phase of combined lymphedema/venous insufficiency treatment: maintenance. If there is a short gap of time to await new compression stockings, you realize that if you discontinue compression therapy while the custom stockings are being made, there is a good chance of the ulcer reappearing. Since there is no reimbursement for continued compression wrapping on intact legs, you place two layers of a tubular compression material over each leg and instruct her to remove the second layer at night to avoid compromising the circulation and replace both layers during the day.
Mrs. S. returns to the clinic in about 3 weeks with her new stockings (ordered in a darker brown color to blend with the patient's natural skin tones better). Her legs have increased slightly in circumference, but thankfully the ulcer has not reopened, and you start her on daily wear of her new stockings with instructions to apply them first thing in the morning when she first wakes up but before she has a chance to walk around, and remove them at night just before retiring to bed. You reinforce washing them by hand at night, air drying overnight for wear the next day, and you schedule a return visit in 2 weeks. If possible, you may consider 2 pairs of stockings – the patient can alternate washing one pair and wearing the other.
