Acording to a best practice statement (Wounds UK, 2019), wound complexity increases the likelihood of wound chronicity and can make a wound hard to heal. A ‘complex’  venous leg ulcer (VLU) has a number of indications that link to lymphovenous disease, namely: 
  • Wound present for more than six months 
  • Current infection and/or history of recurrent infections 
  • Wound has failed to reduce in size by 20–30% at four to six weeks despite best practice
  • Fixed ankle or reduced range of motion 
  • Unmanaged pain 
  • Severe lymphoedema (adapted from Wounds UK, 2019). 
These characteristics are usually seen in most patients who attend the authors’ wound and lymphoedema clinics, with many having the added complication of fibrosed wound beds.  
 
Patients that are seen across the authors’ six clinics predominantly present with lymphovenous ulcers, with the majority of chronic non- or slow-healing ulcers having a degree of limb distortion, with either a subtle or pronounced inverted champagne-shaped leg (Figures 1 and 1a). 
 
Figure 1a and 1b.

FIBROTIC WOUND BED  


Chronic venous insufficiency (CVI) will lead to the development of the inverted champagne bottle leg and is said to be caused by the fibrin cuff (Burnand et al, 1982; Mortimer and Browse, 2003; Williams, 2009). The tissues feel hard and ‘woody’, which is thought to be due to fibrin deposited around capillary beds which, in turn, leads to elevated intravascular pressure (Burnand et al, 1982; Mortimer and Browse, 2003; Williams, 2009). If the pressure is not treated, this leads to lipodermatosclerotic (LDS) changes, i.e. inflammation of the layer of fat under the epidermis. Patients with LDS also develop lymphatic changes, which reduce the capacity of the lymphatic system to function effectively (Williams, 2009). The ‘fibrin cuff’, which surrounds the capillaries in the dermis, decreases oxygen permeability and inhibits diffusion of oxygen and other nutrients, leading to impaired wound healing (Burnand et al, 1982; Williams, 2009).  

In normal wound healing, the response to epithelial cell damage is to produce transforming growth and other factors, which together result in local inflammation and cellular activity essential for wound healing (Artlett, 2012). However, when tissues are subjected to persistent insult and injury, such as  infectious pathogens or autoimmune reactions, this process of repair goes awry (Artlett, 2012). 

This creates a chronic inflammatory environment where cytokines and growth factors are abundantly released, as well as other signalling molecules that act as the principal effectors of the fibrotic process. The resulting fibrotic scar tissue will eventually impede normal functioning of the skin (Artlett, 2012). This process is usually seen in patients with chronic wounds, in particular, those which have a continuous cycle of re-infection leading to the development of lymphatic changes (Figure 2).  

The greater permeability in CVI leads to haemosiderin staining, which results in further extravasation of proteins causing increased oncotic pressure (Farrow, 2010). This, in turn, can affect the nerves, causing pain and discomfort coupled with recurrent cellulitis (bacterial infection of the skin). Fibrosis can also lead to vascular problems and the debris, dead cells, and other by products of wound healing will cause stagnation of the wound environment and slow wound healing (Mortimer and Browse, 2003; Williams, 2009;  
Bjork, 2013).  

In the authors’ clinical experience, until the issue of fibrosis around the wound bed is addressed by clinicians and within the literature, it will be a challenge to promote adequate oxygenation of nutrients to the wound bed and improve lymphatic drainage.  

MODIFIED TREATMENT  

 
Morgan et al (2005) and Green (2007) believe that a modified approach to standard, evidence-based leg ulcer management is required when dealing with patients with chronic oedema and ulceration, rather than those with only  
the latter.  
 
Simple compression will only concentrate the proteins further by removing some of the water. However, the remaining proteins will hold onto water molecules (Farrow, 2010), which is why, in the authors’ clinical experience, treatment needs to be modified to improve lymphatic flow and reduce the effects of fibrosis.  
 
Specific issues associated with managing patients with lymphoedematous ulceration include: 
  • Limb shape distortion  Care of skin creases and folds 
  • Swelling of the toes and forefoot and potential swelling above the knee  
  • Fibrosed wound beds  
  • Hyperkeratosis  
  • Papillomatosis (Green, 2007; Williams, 2009;Farrow, 2010; Ellis, 2015). 
In response to these challenges, the authors’ service has developed modified treatment regimens to deal with the specific issue of lymphovenous ulceration. Patients may require complex decongestive therapy (CDT). Those with large, swollen, distorted limbs with skin problems and fibrosis are usually treated with a course of multilayer lymphoedema bandaging (MLLB) and possibly manual lymphatic drainage (MLD), along with skin care, an exercise programme, psychosocial support and education (Foldi et al, 2000). This intensive therapy programme is used to ‘decongest’ the limb by removing fluid from the congested tissues, encouraging the movement of fluid through the lymphatic pathways, and reshaping the oedematous limb (Green, 2007).  
 
One issue seen is chronic oedema in the toes, knees and thighs caused by venous bandaging, which tends to exacerbate ulceration and prevent healing (Williams, 2003; Green 2007) (Figure 3).  
To prevent this in the thighs, bandaging above the knee and to the thigh can be replaced by wrap systems, compression hosiery, or simple lymphatic drainage techniques, depending on the type and severity of the swelling.  

Therefore, to achieve the goals related to lymphatic treatment, healthcare professionals need to incorporate stiffer levels of compression, exercise, manual and simple lymphatic drainage (SLD) techniques and the introduction of adaptive foams and fibrotic tissue softeners (Williams, 2003), including the use of kinesio tape, which is effective in the treatment of lymphoedema (Blanco and Gonzalez, 2020. 

ADAPTATIONS TO BANDAGING TECHNIQUES  

The use of compression therapy aims to achieve different outcomes for venous and lymphatic disease (Williams, 2009; Charles 2013).  
 
Venous 
 
For venous ulceration, compression bandaging and exercise aim to:  
  • Reduce venous reflux and improve venous return 
  • Reduce venous hypertension 
  • Maximise the calf muscle pump 
  • Reduce elevated matrix metalloproteinase (MMP) levels to promote healing of venous leg ulcers (Partsch and Mortimer, 2015).  
 
Lymphoedema  
 
For lymphoedema, compression therapy is used to: 
  • Reduce formation of excess interstitial fluid by opposing fluid filtration from blood capillaries into the tissue, thereby decreasing the lymphatic load 
  • Ensure that fluid is shifted into areas with functional lymphatics 
  • Increase lymphatic reabsorption and stimulation of lymphangion contractions  
  • Enhance the muscle pump, resulting in increased frequency and amplitude of lymph collector contractions  
  • Break down fibrosclerotic tissue (European Wound Management Association [EWMA], 2005). 
 
Compression bandages are usually short-stretch, applied to the whole leg in a figure-of-eight rather than a spiral, to increase pressure and stiffness (toe-to-thigh if required) and prevent displacement of oedema into these areas (i.e. toes, knees and thighs). The high working pressures applied by bandages stimulate lymphatic pumping and reabsorption of lymph (Moffatt et al, 2005; Charles, 2013). 
 
However, for patients with ulceration due to lymphoedema, where there is an area of fibrosis, bandages should be applied as a  ‘criss cross’ or ‘star’, with a cohesive short-stretch bandage over the fibrosed tissue to add additional pressure to that area (Atkin and Sykes, 2015).  
 
The authors’ service has also introduced a strapping technique (Hopkins et al, 2011), which uses cohesive inelastic compression bandaging in narrow straps layered in a fan distribution over the ulcer and oedema. This allows higher compression to the retromalleolal area (Hopkins et al, 2013).  
 
The Putter technique is also utilised for ulceration due to oedema, which is the application of a short-stretch bandage applied as usual and applied to fill any ‘soft’ spots (where fibrotic changes end in the skin, i.e. where the lymphatics are draining to [Wigg, 2016]).   

ADJUVANT TREATMENT OPTIONS 

 
There are a variety of adjuvant treatments for fibrosis in lymphovenous disease, including:  
  • Creative foam applications, such as chip pads or custom-cut, flat foam pieces (Hodgson et al, 2011)  
  • Strapping techniques to manage areas of densely fibrotic tissue and retromalleolor fossa ulcers (Hopkins et al, 2013)  
  • MLD or SLD (Bertelli et al, 2013)  
  • Low level laser therapy (LLTT) (Wigg, 2009) 
  • Kinesio tape (Blanco and Gonzalez, 2020) 
  • Adapting bandaging techniques, such as applying inelastic compression bandages in a figure-of-eight application rather than a spiral for those with late-stage lymphoedema (Moffatt et al, 2005; Charles, 2013; Whitaker et al, 2015); utilising the Putter technique; or applying above the knee to the thigh bandaging (Elwell, 2015) 
  • Knee and thigh compression wraps (Mosti et al, 2015). 
 
This article will now look at each method and how to implement in practice, with some case studies where the authors have used these techniques to reduce fibrosis and see what potential effect the treatments had on outcomes.  
 
Foam applications 
 
These therapies help to maximise the effect of compression bandages by distributing consistent pressure over a greater surface area within the bandage structure (Hodgson et al, 2011).  
 
They consist of chip pads, silicone pieces, cut foam and adapted cut foams. These are placed either around the wound bed or over the area of fibrosis on top of a primary dressing. The bandages are then applied (Figures 4)

Figure 4.
Foam and compression is a technique used by many lymphoedema therapists to help reduce tissue fibrosis (Hodgson et al, 2011). Channeled foam can be used to help create tissue stretch and move lymphatic fluid along the lymphatic pathways, by pushing lymph from the high-pressure areas and allowing it to drain proximally through the low-pressure areas (Farrow, 2010). 
 
Case studies for foam pads and strapping 

Patient A had leukaemia and an ulcer of over six months’ duration (Figures 5 and 5a). Treatment incorporated a short-stretch bandage applied in a figure-of-eight, retromalleolar strapping and a chip pad. The periwound area softened and the wound went on to heal within six months, despite the patient’s multiple comorbidities.  

Patient B had swelling to the toes and foot and fibrosed oedema to the retromalleolar area of the leg, with longstanding chronic venous hypertension which had resulted in lymphatic changes (Figures 6 and 6a).  

He was treated with a short-stretch bandage applied in a figure-of-eight and strapping. The patient had a fibrosed wound bed with atrophie blanche surrounding the periwound area. The area reduced in size by 1cm within a four-week period.  

Patient C had mixed venous arterial disease and an ulcer present for two months, which had been treated with full compression therapy (Figures 7–7c). Her left leg had strapping applied over a double layer short-stretch bandage, which softened the fibrotic area and, as a result, the wound reduced in size by 0.5cm in four weeks and the pain the patient was experiencing at the wound bed reduced.  

Patient C also had ulcers on her right leg, for which she was treated with a combination of strapping and Mobiderm foam padding (Thuasne). The ulcer size reduced by 15.5cm2, with softening of the periwound area within a four-week period.  

Manual/simple lymphatic drainage (MLD/SLD)


Patients may require a degree of MLD. The technique employed by the authors is the FGMLD ‘Fill and Flush’ (Wigg, 2015). This is a research-based technique which moves fluid to drainage points on the limb, which are located using the skin pinch test. Skin around the wound site needs to be assessed by modifying the Stemmer’s test to examine skin texture in affected areas (Bjork, 2013). If you can pinch and lift the skin, the test is negative, if you cannot, it is positive. This means that lymphatic drainage is poor to the area and you need to find a ‘soft spot’ into which to drain fluid.  

Skin that is positive for lymphoedema will be thickened, less pliable and produce limited or no ‘bow tie’ of wrinkles (Figure 8), which is indicative of chronic inflammation, tissue thickening and fibrotic soft tissue changes (Bjork, 2013; Wigg, 2015) (Figure 9).  

As part of the treatment plan, the authors also teach patients and family members/carers how to administer SLD. Plans are developed based on lymphatic drainage pathways. If fluroscopy (a method of mapping and identifying superficial drainage pathways, which then allows clinicians to map drainage routes and target treatment — currently only available privately in the UK) cannot be accessed, the authors’ service use the pinch test to identify potential drainage pathways to ensure when bandaging or kinesio taping can be used to push fluid to the draining areas of the leg (Farrow, 2010).  

Low level laser therapy (LLTT)

 
LLLT or photobiomodulation therapy is a laser or LED light therapy, which is claimed to improve:  
  • Tissue repair 
  • Inflammation 
  • Oedema  
  • Pain (Pillar et al, 1998; Shubert, 2001; Carati et al, 2003; Kozanoglu et al, 2009; Minatel et al, 2009; Omar et al, 2012). 
The aim of LLLT is to soften thickened and fibrosed tissues, reduce inflammation and therefore the risk of cellulitis, and lessen the viscosity of the lymph to improve lymph flow and overall limb volume reduction (Elisaka and Eliskova, 1997). Treatments typically take 1–10 minutes and should be applied two or more times a week. Combining LLLT therapy with other aspects of lymphoedema management, such as strapping techniques, bandaging and MLD, can help to reduce ‘stubborn’ swelling in the affected area.  
 
LLLT has been shown to have an effect on lymphoedema secondary to cancer, with reported improvements including the reduction of tissue hardness and limb volume (Pillar et al, 1998; Kozanoglu et al, 2009; Omar et al, 2011), and softening of scar tissue and increased mobility (Carati et al, 2003; Wigg, 2009; Omar et al, 2011). Work in the UK has found that patients with lymphoedema and fibrotic tissue have increased softening in comparison to standard treatment. When delivered as an adjunct therapy, it enhances the effect of MLD and compression (Wigg, 2009). 
 
Studies investigating whether LLLT can be useful as an adjunct to conventional wound healing therapies have shown higher healing rates (Schubert, 2001), especially in wounds that have failed to respond to other forms of treatment (Minatel et al, 2009). Dyson et al (2001) found that the healing of acute wounds can only be stimulated by LLLT if they are healing sub optimally, as it encourages granulation tissue production and wound contraction.  
 
Therefore, the evidence may highlight the benefit in cases where conventional treatment has not been successful, which links to the effects it has on fibrosis in lymphoedema, meaning that LLLT potentially warrants further study.
Case studies for LLLT 

Figures 10 and 10a show patient D who presented with a mixed aetiology ulcer which had been present for over six months. The patient had not been responding to conventional therapies and was experiencing pain, which reduced the ability of the nursing team to apply optimal compression levels. It was thus decided to start LLLT. The patient’s pain reduced within two weeks allowing the team to apply appropriate compression. The periwound fibrosis subsequently reduced and softened and the ulcer went on to heal.   

Patient E (Figures 11 and 11a) had a venous leg ulcer with atrophie blanche surrounding the periwound area. It was decided to treat with LLLT and foam padding. By week four, the periwound skin had softened and the wound was reducing in size.  
 

Kinesio tape

Kinesio tape is a therapeutic taping technique to alleviate pain and facilitate lymphatic drainage by microscopically lifting the skin (Blanco and Gonzalez, 2020). This lifting effect forms convolutions in the skin, increasing interstitial space and decreasing inflammation in affected areas by allowing blood and lymph to dilate and drain. The tape increases the space in which lymphatic fluid flows, enabling it to move towards working lymph nodes. It can also help to facilitate the stretch response of the angions, with movement or muscle contraction (Blanco and Gonzalez, 2020). 

Kinesio tape is applied with differing tensions to areas of oedema and fibrosis, following the identified lymphatic drainage pathways identified by the pinch skin test (Figure 8). 
 
Case studies for kinesio tape

Patient F had a haematoma and was also morbidly obese and refused any form of compression. Kinesio taping was started following the lymphatic drainage pathways and the wound healed within three months (Figures 12–12b). 

Patient D had lymphovenous disease with lymphorrhea and recurrent fungal infections to the toes, which had not been controlled with conventional toe and stump bandaging techniques and appropriate antifungal treatments (Figure 13). Kinesio tape was applied following the drainage pathways, (Figure 13a) and then a short-stretch  8cm bandage was applied in a figure-of-eight to the ankle and a 10cm bandage applied in a figure-of-eight to below the knee, finishing with 10cm spiral toe-to-knee bandaging. This treatment regimen resulted in the lymphorrhea and superficial ulcer healing within  
four weeks.   

Patient G had a small retromalleolar ulcer which had not been responding to conventional bandaging techniques or strapping. Kinesio tape was applied over the primary dressing to reduce the fibrosis and assist healing, which subsequently occurred (Figures 14–14b). 

Patient H had a venous leg ulcer which had been present for six months with a fibrosed wound bed. A two-layer elastic/inelastic combination bandage system was applied along with kinesio taping to a draining soft spot on the patient’s leg. The periwound fibrosis softened and the wound reduced in size after four weeks of treatment (Figure 15 and 15a).   

The patients involved in these case studies were referred to the authors’ specialist wound and lymphoedema service as they were non-healing at six weeks, despite receiving compression therapy. With the introduction of appropriate adjuvant treatment options, the wounds progressed to healing. In the authors’ clinical opinion, the effect of modified therapies on the fibrotic wound bed and periwound skin needs further investigation.
 
 
Figure 13

Figure 12.

Figure 14

Figure 15

CONCLUSION 


In the UK, many areas either do not have lymphoedema specialists or have been withdrawing services. This has passed the care onto generalist healthcare professionals, resulting in a failure to meet international standards for the management of lymphoedema (Macmillan Cancer Support, 2011). Management of chronic oedema and lymphoedema requires knowledge, understanding and skill in assessment, diagnosis and management, as well as knowledge of physical and psychological sequelae of the condition (Williams, 2009).  

Specialist lymphoedema and wound care services need to educate and improve healthcare professionals’ knowledge base and stop the delay in referral to appropriately trained clinicians (Harding et al, 2015), which increases severity of symptoms, leading to patients enduring unnecessarily protracted intensive treatment packages that are more labour and resource intensive (Todd, 2019). Inappropriate disease management can also result in unnecessary complications, such as recurrent infection, pain, increased swelling, and poor outcomes for patients (Ellis, 2015). 

The lymphatic system should be targetted to trigger an immune response to balance the bioburden of the wound and reduce the cycle of recurrent infection (White et al, 2014; Stanton, 2020). If the lymphatics are static, dead cells, debris and other by products of wound healing remain, causing stagnation of the wound environment and delayed  
wound healing. 

The introduction and adaptation of CDP, consisting of MLD/SLD, compression bandaging, remedial exercises and skin care, mobilises accumulated oedema fluid and increases lymph flow, resulting in a beneficial therapeutic effect on fibrosclerosis (Foldi et al, 2000),  as seen in the case studies presented here.  

Adaptation of pathways to include treatment to break down fibrosis in the wound bed to improve lymphatic drainage (Elwell, 2015), and, ultimately, the microcirculation, is essential in wound care and, in the authors’ clinical opinion, should be encouraged to improve outcomes in complex chronic leg ulceration caused by lymphovenous disease. Interventions to help prevent damage to lymphatic capillaries and techniques to facilitate lymphatic drainage and lymphangiogenesis need to be considered as part of routine wound management (Bjork and Hettick, 2018).  

The introduction of tissue viability nurses with lymphoedema expertise should be encouraged within leg ulcer clinic settings to improve patient outcomes. Alongside this, controlled trials should be undertaken to look at evaluating these techniques to ascertain whether outcomes and healing times are improved, as well as which techniques or combinations are more effective. 

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