Lymphoedema Evidence Library › Topics › Wounds, skin and cellulitis
Wounds, skin and cellulitis
Wounds, skin and cellulitis
76 sources
Evidence in one minute
- Skin care is fundamental to every lymphoedema programme: cleansing, low-pH emollients, inspection and treatment of fungal infection. Hygiene cuts filarial acute attacks by about two-thirds. Executive Committee of the International Society of Lymphology 2023 · Stocks 2015
- Recurrent cellulitis: penicillin V 250 mg twice daily for 12 months halves recurrence while taken (22% v 37%, NNT 5), and the effect stops when it is stopped — high certainty for recurrent cellulitis, moderate in lymphoedema (PATCH I). Leg lymphoedema, BMI ≥33 and several prior episodes predict a poorer response, so treat the oedema too. Thomas 2013
- Acute cellulitis: antibiotics for true infection (fever, pain, spreading erythema); a UK audit found only 14% received first-line amoxicillin. Keeley 2009
- Wounds in lymphoedematous legs: treat the oedema, not just the wound — compression chosen by limb shape plus exudate-appropriate dressings, with ABPI and clinical judgement. Keast 2025 · Davey 2014
- Biopsy the atypical or non-healing lesion: Stewart–Treves angiosarcoma mimics bullous erysipelas; basal cell carcinoma and Kaposi sarcoma also occur. da Costa Vieira RA 2019
- Lymphoedematous limbs are not hypoxic on TcPO2 (arm data); a low reading suggests arterial disease. Mayrovitz 2005
Cellulitis
- Prophylaxis: PATCH II, after mostly first episodes, was inconclusive (low); the PATCH protocol is held. Long-acting benzathine penicillin (1.2 MU IM every 2–3 weeks) was linked to far fewer recurrent attacks in Indian leg lymphoedema (16% v 76%; non-randomised, very low), and long-term benzathine penicillin cut recurrence in an open study. UK Dermatology Clinical Trials Network’s PATCH Trial Team 2012 · UK Dermatology Clinical Trials Network PATCH Study Group 2007 · Olszewski 2005 · Olszewski 1996
- Reducing the oedema reduces cellulitis: 63% had no further cellulitis after complex physical therapy; lymphatic microsurgery reduces cellulitis frequency in uncontrolled series (low; revised 2026-10-08); the only LVA RCT lost a third of randomised patients (very low). Penicillin prophylaxis remains the best-supported measure. Földi 1996 · Gloviczki 2026 · Mihara 2024
- Risk: larger limb excess (OR 1.07 per %) and primary lymphoedema (OR 3.4) — case–control, very low; 77% of patients with recurrent erysipelas have abnormal lymphoscintigraphy. Teerachaisakul 2013 · de Godoy JM 2000
- Nature: "cellulitis" in lymphoedema may be partly sterile inflammation (Suehiro); Olszewski counters that bacteria and penicillin prophylaxis matter. Suehiro 2018
- Persistent pain after cellulitis: image for a deep abscess (piriformis pyomyositis case). Tsujita 2025
Wounds and skin
- Hyperkeratosis: washing, emollients, keratolytics and mechanical debridement. All Wales Tissue Viability Nurse Forum 2014
- Venous overlap (phlebolymphoedema): ICG shows lymphatic dysfunction in venous ulcers (Rasmussen 2016, cited in the Vivian case); 10 days of MLD plus compression healed more venous ulcers than compression alone (pilot, 26 patients). Single cases show what inelastic compression does to ulcers and oedema, without a comparator. Vivian 2019 · Szolnoky 2018 · van Zanten M 2013
- Pathways: WAWLC — control peri-wound oedema; industry pathway sheets (Wounds UK 2014 with BSN, 2022 with medi) are brand-led and unreferenced — use their structure, not their product choices. World Alliance for Wound and Lymphoedema Care 2009 · Wounds 2014 · Wounds 2022
- Massive localised lymphoedema mimics sarcoma. Fife 2014
- Myiasis: check open lesions on tropical lymphoedematous legs for fly larvae (2.5% in Recife); oral ivermectin clears them. Dreyer 2008
Malignancy in lymphoedema
- Stewart–Treves angiosarcoma also arises in primary and post-traumatic lymphoedema; most lymphoedema physiotherapists feel unable to recognise it. Schmitz-Rixen 1984 · Trattner 1996 · Maccio 2025
- A basal cell carcinoma was treated with dressings for 3 months (patient account); Kaposi sarcoma (HIV) is the local malignancy to exclude. Hasznosy 2012 · Ebrahim 2009
Gaps and warnings
- Do not follow the Alavi/Sibbald chapter on drugs: it calls warfarin "coumarin, a benzophenone", describes benzopyrones as low-toxicity (coumarin was withdrawn for liver toxicity) and advises doxycycline, trimethoprim or erythromycin prophylaxis instead of penicillin V. Its skin-care and compression-by-ABPI sections are usable. Alavi unknown
- No trial compares wound outcomes with and without lymphoedema treatment.
For the therapist
- Do: daily cleansing and emollient; check between toes for fungal infection; teach patients the signs of cellulitis and to start antibiotics early; refer for penicillin prophylaxis after two or more episodes (high certainty for recurrent cellulitis).
- Stop: applying compression over acute cellulitis until antibiotics have started; dressing non-healing ulcers in long-standing lymphoedema without asking for a biopsy.
- Refer urgently: purple papules, atypical "cellulitis" that does not settle, or rapidly increasing swelling.
- Certainty: penicillin prophylaxis high; hygiene packages very low but consistent.
For a vascular surgeon in South Africa
- Offer penicillin V prophylaxis after two or more episodes despite good oedema control; benzathine penicillin is an option where adherence is poor.
- Biopsy purple papules, atypical "cellulitis" and non-healing ulcers in long-standing lymphoedema, and test for HIV.
How the evidence points
| High | Mod. | Low | V. low | None | |
|---|---|---|---|---|---|
| Positive | 1 | 0 | 1 | 3 | 0 |
| Null or negative | 0 | 4 | 1 | 0 | 0 |
Sources on this page with a comparison, by the result of their primary outcome and the GRADE certainty of their main finding (Mod. = Moderate, V. low = Very low, None = not graded). Context sources are not counted. How direction is decided.
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