Gradient pressure garments
Gradient pressure garments (also known as lymphedema sleeves or stockings) generate greater pressures distally than proximally, which enhances mobilization of edema fluid. Some patients may require custom-made sleeves to achieve an appropriate fit. The use of these garments may be especially important at high altitudes, such as during air travel, because the ambient atmospheric pressure is less than the outlet transcapillary pressure within the superficial tissues, which can lead to worsening edema.
Bandaging involves the use of inelastic material to discourage reaccumulation of lymph by reducing capillary ultrafiltration and optimizing the efficacy of the intrinsic muscle pump. Bandaging may change an initially resistant limb to one with less edema, resulting in decreased limb volume and allowing a garment to be applied successfully.[Level of evidence: I]
The goal of skin care is to minimize dermal colonization by bacteria and fungus, especially in the crevices, and hydrate the skin to control dryness and cracking.
Complex decongestive therapy
Complex decongestive therapy is a multimodality program that consists of manual lymphedema drainage therapy, low-stretch bandaging, exercises, and skin care. This approach has been recommended as a primary treatment by consensus panels and as an effective therapy for lymphedema unresponsive to standard elastic compression therapy.[9,10]
Complex decongestive therapy is divided into two successive phases. The first phase consists of intensive treatment to allow substantive reduction of lymphedema volume. The second phase consists of maintenance treatment at home. Compliance with the use of the elastic sleeve and low-stretch bandage has been found to be an important determinant of success with maintenance therapy at home. Complex decongestive therapy has also been shown to improve lymphedema following groin dissection. Patients should be referred to a properly trained therapist for optimal results.
Intermittent external pneumatic compression
Intermittent external pneumatic compression may also provide additional improvement with lymphedema management when used adjunctively with decongestive lymphatic therapy. One small randomized trial of 23 women with new breast cancer–associated lymphedema found an additional significant volume reduction when compared with manual lymphatic drainage alone (45% vs. 26%).[Level of evidence: I] Similarly, improvements were also found in the maintenance phase of therapy. Concerns regarding the use of intermittent pneumatic compression include the optimum amount of pressure and treatment schedule and whether maintenance therapy is needed after the initial reduction in edema.[Level of evidence: I] There is a theoretical concern that pressures higher than 60 mmHg and long-term use may actually injure lymphatic vessels.