What is fibrosis?
Fibrosis in lymphoedema relates to an area of a limb that has become firmer, harder and less elastic than normal tissue (Figure 1). It is due to the formation of fine scar-like structures which develop from the protein-rich fluid within the tissues found in limbs with lymphoedema. The amount of swelling (or oedema) is not an indicator to the risk of developing fibrosis as unfortunately, it can develop even in the smallest of lymphoedematous limbs.
How does fibrosis develop?
Early stage lymphoedema often presents with a mild, soft swelling (a protein-rich fluid within the tissues) that tends to be intermittent and reduces slightly overnight with elevation. The swelling is often ‘pitting’ which means it is easily indented, often with minimal pressure (see Figures 2 and 3). With prompt, early intervention it can be effectively managed and controlled with appropriate treatment such as compression, exercise, and skin care.
If left untreated however, the protein rich fluid becomes stagnant and the soft tissues become harder, firmer and less elastic – fibrosis in lymphoedema. Pitting of the swelling becomes increasingly difficult and the Stemmer’s sign is positive. Stemmer’s sign (Figure 4) is the inability to pick up a fold of skin at the base of the fingers or toes. This is a positive indicator of lymphoedema as the tissues are firm and less elastic.
Potential complications of fibrosis
As fibrosis in lymphoedema develops, the tissues become more congested and it becomes increasingly difficult for tissue fluid to drain away. The protein molecules accumulate in the tissues and cause more fibrosis and inflammation with an increased risk of skin problems. For example, local induration (thickening of the skin) and a deepening of natural skin folds (often evident at the base of fingers, toes, ankle and wrist joints) and infection such as cellulitis.
Can I prevent fibrosis developing?
The earlier lymphoedema is treated, the less likely it is for fibrosis to develop. Lymphoedema treatment should therefore begin as soon as signs are detected, even if they are not yet visible. For example, the limb may feel tight and/or heavy. Early, prompt referral can be helpful to ensure appropriate treatment begins as soon as possible. In lymphoedema, the use of water-tablets (diuretics) is not recommended, even if the swelling is soft and pitting. Using diuretics may just remove the water content of the swelling leaving the high protein, inflammatory products in the tissues which may lead to further fibrosis.
How is fibrosis treated?
If fibrosis has become a problem, then every effort should be made to try to soften the fibrotic area. This can be done through Manual Lymphatic Drainage (MLD) (Figure 1). The lymph drainage techniques used are firmer over the affected area to try to break up the protein deposits and inflammatory effects. You may also be shown techniques to do this yourself at home (Self Lymphatic Drainage) as the more often the area is treated, the more the fibrosis responds.
Compression (such as bandages or compression garments) is an important component of treatment and should be used as much as possible. Compression may be combined with textured, foam pads. Skin care and exercise are also important components. Some lymphoedema clinics may use other equipment that have been designed to assist such as low-level laser therapy (LLL) and negative pressure treatments.
In conclusion, fibrosis is a potential complication of lymphoedema that can lead to worsening and progression of the condition. Any changes in the tissues of a lymphoedematous limb (or a limb at risk of lymphoedema) should not be ignored. Instead, consult your GP, lymphoedema therapist or healthcare professional as soon as possible to commence the most appropriate treatment.
Above: Figure 1
Above: Figure 2
Above: Figure 3
Above: Figure 4