WHAT IS CELLULITIS? Cellulitis further damages lymph drainage routes and therefore increases the risk of worsening the swelling.

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1 WHAT IS CELLULITIS? What is cellulitis? Cellulitis is a sudden, non-contagious infection of the skin, characterised by redness, swelling and heat, accompanied by pain and tenderness. People with lymphoedema are particularly susceptible to cellulitis because the lymphatic system is damaged and frequently does not function adequately to fight infection. What causes cellulitis? The cause is nearly always a bacterial infection, usually a bacterium called Streptococcus, but other bacteria may be involved. The infection may enter via a break in the skin, such as a scratch or insect bite, or through a pre-existing wound or ulcer, or through an area of skin inflammation, e.g. athlete s foot, eczema or dermatitis. Alternatively, it may not be possible to identify any predisposing factors and an attack may arise without warning. Why does cellulitis occur in lymphoedema? The lymphatic system is not only important for draining fluid away from tissues, but is also important for policing or patrolling for infection. This is why lymph glands become tender or enlarged in response to infection, e.g. lymph glands in the neck can enlarge with a sore throat. Consequently, if the lymphatic system is not working well, infection may not be dealt with properly by the body. The fault in immunity is confined to the region affected by the lymphoedema and does not apply to the body generally. Cellulitis further damages lymph drainage routes and therefore increases the risk of worsening the swelling. THE LYMPHOEDEMA SUPPORT NETWORK Page 1

2 How can I recognise cellulitis? The patient often feels unwell, as if flu is starting. Symptoms can include fever, shivers, muscular aches and pains, headache, nausea, vomiting, etc. The swollen area usually develops a rash or becomes red, hot and tender to the touch. Swelling may dramatically increase and pain may occur in the swollen area, or the armpit with lymphoedema of the arm, or groin with lymphoedema of the leg. Cellulitis may follow an event such as an accidental scratch or cut to the skin, or an insect bite, but in many cases the cause is not obvious. Recurrent cellulitis Attacks of cellulitis recur within the region affected by lymphoedema. Recurrence may be infrequent or occur every few weeks. It is not known if each episode is due

3 n Patients with severe constitutional upset may require admission to hospital for intra-venous antibiotics. n Those patients familiar with attacks and who have appropriate oral antibiotics to hand should commence the course immediately. n All compression garments should be removed and other forms of lymphoedema treatment such as Manual Lymphatic Drainage (MLD) therapy and exercise programmes temporarily suspended. Compression garments should be reapplied when the limb feels comfortable. n Rest is necessary, with the affected limb elevated in a comfortable position, ideally raised to the same level as the chest (heart level). n Plenty of water should be drunk. n Painkillers, e.g. Paracetamol. Anti inflammatory medications such as Ibuprofen should be avoided. What do I do after an attack? As signs of inflammation subside, your limb may remain more swollen than it was before the attack. When to re-introduce your usual regimen of exercise and compression garment is a matter of judgement. You must wait until the increased swelling has eased before re-applying your sleeve or stocking. A garment that is too tight or poorly fitting may do more harm than good. You must not return to normal activities without wearing your compression garment and, therefore, an extended period of elevation may be necessary before re-applying your garment. Exercise should be re-introduced gently. If there are any signs of relapsing inflammation, you should return to rest and elevation and consult your GP. How can I prevent cellulitis? What is cellulitis? fact sheet n All patients with lymphoedema should be warned about cellulitis and how it might affect them. n The skin needs to be in the best possible condition if it is to resist damage and reduce the risk of infection. Improving the skin barrier is best achieved by using emollients (moisturisers) regularly (For more information, see the LSN Skin Care fact sheet). n Every effort should be taken to avoid skin injury, e.g. cuts, burns, or injections to the lymphoedematous site or adjacent area. Use an electric razor to reduce the risk of cutting your skin and take care when cutting nails. If your leg is swollen, do not walk barefoot. Wear comfortable, well fitting shoes. n Treat cuts and abrasions immediately with antiseptics and cover with a dressing. n Athlete s foot (whitening, itching or peeling of skin between the toes) should be treated with twice daily application of Terbinafine cream (Lamisil) for 2 weeks. This can be bought without prescription and should be used as instructed by the leaflet provided with the cream. For any other skin conditions e.g. dermatitis, ulcers, warts, etc. and for conditions affecting the finger and toe nails, please consult your doctor. n Reducing the swelling may prevent, or at least reduce, the number of attacks of cellulitis. Thus, appropriate, effective treatment of the lymphoedema is essential (but not until all signs of infection have cleared). n It is important to ask your doctor to supply a course of antibiotics in case of need when travelling, particularly to places where immediate medical help may not be available. THE LYMPHOEDEMA SUPPORT NETWORK Page 3

4 What do I do if cellulitis recurs? In some cases where cellulitis recurs more than twice per year, it may be justified for your doctor to prescribe antibiotics to take every day. This is referred to as antibiotic prophylaxis. For how long antibiotic prophylaxis should be continued depends on each patient s needs; life-long usage may be necessary, particularly if the cellulitis recurs when prophylaxis is discontinued. It is not unusual, following two years of successful prophylaxis, for cellulitis to recur immediately the antibiotics are stopped; indicating that cure of the infection may not be possible. Life-long penicillin is quite safe and has been used in this way for decades without adverse effect, in patients who have had their spleen removed. Long term use of more broad-spectrum antibiotics, e.g. erythromycin, may be necessary in some cases. This approach is also safe and preferable to unpredictable attacks of cellulitis. For more information, see the LSN fact sheet Management of Cellulitis in Lymphoedema. Contributors What is cellulitis? fact sheet Professor Peter S. Mortimer, Consultant Dermatologist at the Royal Marsden and St. George s Hospitals, London Dr Christopher Cefai, Consultant Microbiologist, NE Wales NHS Trust Dr Vaughan Keeley, Consultant in Palliative Medicine, Royal Derby Hospital, Derby. Eilish Lund, Macmillan Lymphoedema Nurse Specialist, Nightingale House Hospice, Wrexham LSN Trustees Reviewed 03/10 THE LYMPHOEDEMA SUPPORT NETWORK Page 4

5 What is cellulitis? fact sheet LYMPHOEDEMA IS THE SWELLING OF THE LIMBS AND BODY DUE TO THE ACCUMULATION OF LYMPH. Lymphoedema affects at least 100,000 men, women and children in the UK causing swelling of the limbs or body and an increased risk of infection (cellulitis). However, it remains an underestimated health problem and is little known or understood by many medical practitioners. The Lymphatic System Lymph is a colourless fluid which forms in the body. It normally drains back into the blood circulation through a network of vessels and nodes. Lymph nodes act as filter stations and they play an important part in the body s defence against infection, by removing excess protein, cells (which may include cancer cells) and microorganisms. Why does lymphoedema occur? If the drainage routes through the lymphatic system become blocked or damaged, lymph accumulates in the tissues and swelling (oedema) occurs. Unlike other oedemas, lymphoedema leads to changes in the tissues such as fibrosis (hardness) and an increased risk of infection. The swelling can then become even more difficult to control. Primary and Secondary Lymphoedema Primary Lymphoedema develops as a result of a fault within the lymphatic system itself - usually as a result of genetic underdevelopment or weakness of the lymph conducting pathways. It can affect children and men or women at any age. Secondary Lymphoedema is the result of damage to lymphatic pathways. This maybe the result of treatment for cancer following surgery or radiotherapy. It can also occur as a result of infection, severe injury, burns, or any other trauma that can damage the lymphatic nodes/vessels. It can also arise as a result of the venous system not working efficiently (i.e. those who have had a deep vein thrombosis (DVT), varicose veins or varicose ulcers). Those patients suffering from lack of muscle movement (i.e. those suffering from a stroke or Multiple Sclerosis) may also be at risk. EARLY DIAGNOSIS AND EARLY TREATMENT ARE VITAL TO CONTROL LYMPHOEDEMA. Become a member of the LSN see next page. THE LYMPHOEDEMA SUPPORT NETWORK Page 5

6 What is cellulitis? fact sheet The LSN is a registered charity founded in It provides vital information and support for people with lymphoedema, while working towards the availability of better national resources for lymphoedema treatment. What the LSN offers to members: n Telephone information and support line n Quarterly newsletters containing current information on lymphoedema, research and treatment n A wide range of gold standard fact sheets n A frequently updated website n Self-help DVDs n School packs The LSN relies solely on membership subscriptions and donations. Please help us to continue our vital work by becoming a member and/or making a donation. APPLICATION FOR MEMBERSHIP Mr, Mrs, Miss, Ms. s u r n a m e First names Address Post Code Telephone (Home) (Work) I have Lymphoedema I am a Health Care Professional Other (please specify) I would like to join the LSN and enclose a cheque made payable to the LSN for Annual UK subscription Annual overseas subscription Donation to support the work of the LSN of Total Please send to: The Lymphoedema Support Network St Luke s Crypt, Sydney Street, London SW3 6NH THE LYMPHOEDEMA SUPPORT NETWORK Page 6

7 What is cellulitis? fact sheet Fact sheets available: Coping following a mastectomy/lumpectomy Breast oedema The management of cellulitis in lymphoedema Recreational exercise with lymphoedema Manual Lymphatic Drainage Therapy Skin care for people with lymphoedema The use of compression garments in lymphoedema management Holidays and travel Prevention of lower limb lymphoedema Reducing the risk of upper limb lymphoedema For information and help, please contact The Lymphoedema Support Network St Luke s Crypt, Sydney Street, London SW3 6NH Telephone: (Information and Support) (Administration) Facsimile: adminlsn@lymphoedema.freeserve.co.uk Website: Registered Charity No Patron Zoë Wanamaker CBE THE LYMPHOEDEMA SUPPORT NETWORK LSN 03/2010 THE LYMPHOEDEMA SUPPORT NETWORK Page 7