How to detect skin changes associated with venous and lymphovenous disease14th October 2013
Have you ever noticed how small things can get worse over time without you even noticing? Like that list of patient referrals you keep meaning to tackle that’s clogging-up your inbox? Or that nursing home that keeps reporting pressure ulcers but promising you they’ll try harder? What seems like a series of minor problems can eventually turn into a crisis and before you know it you’ve got a full-scale emergency on your hands.
The same principle applies to venous and lymphovenous disease — skin changes to patients’ legs occur gradually at first, but can become serious if left untreated and mild symptoms such as varicose veins can eventually lead to leg ulceration or chronic oedema if the underlying disease process is not addressed. As with many other chronic conditions that develop slowly, the key to prevention is knowing what to look for.
Patients with disease of the venous and/or lymphatic system undergo a number of skin changes to their legs (Timmons and Bianchi, 2008) and these can easily be detected during routine cleaning and assessment of the patient’s legs and skin. Knowing what these signs are and looking for them during skin/wound assessment means that patients can receive prompt intervention that can stop the disease progressing or improve existing symptoms.
Using a specifically designed toolkit to identify the signs and symptoms of venous and lymphovenous disease makes skin changes easier to spot in clinical practice. The CHRonic Oedema Signs and Symptoms (CHROSS) Checker kit also provides recommendations for the most appropriate compression hosiery you should choose to manage underlying disease (according to the severity and type of signs/symptoms) as part of an overall treatment plan.
This article explains what causes the changes in a patient’s skin as well as how to spot the danger signs that can indicate venous and lymphovenous disease.
Understanding how the venous and lymphovenous systems work
Before you can begin to tackle any skin changes on your patient’s lower limbs, it is important to understand the physiology behind any signs and symptoms.
The arteries take blood away from the heart, transporting oxygen and nutrients around the body, whereas the veins return the blood to the heart. Arteries have thick elastic walls and eventually lead to smaller vessels (arterioles), then into the even smaller capillaries, which branch out into the body’s tissues. The walls of the capillaries are very thin (one cell thick) so that oxygen, glucose and other substances can pass through them into the interstitial fluid (the fluid that bathes all of the cells in the body), then into the tissues and organs.
The capillaries are where the arterial system ends and the venous system begins. Blood flows from the capillaries into small veins (venules), which in turn feed the larger veins that return deoxygenated blood and waste back to the heart. The blood travelling in the veins is under less pressure than in the arteries, so these vessels have thinner walls. This means they can expand depending upon the volume and pressure of blood inside — if there is a low volume of blood and low pressure in a vein it will flatten; if the volume and pressure increases, the vein expands (Starr et al, 2008; Koeppen and Stanton, 2010).
In the lower limbs, blood returning to the heart has to push against gravity, which sometimes causes it to flow backwards. When this happens, one-way valves in the veins will close, preventing a ‘pooling’ of blood in the lower legs (Anderson, 2006; 2008). The flow of blood back towards the heart from the legs is encouraged by gravity, lying down or elevating the legs, breathing and, importantly, through the action of the calf-muscle pump.
The importance of the ‘second heart’
The blood in the leg veins is also forced upwards by the contraction of the calf muscle during walking or exercise, often termed the ‘second heart’. The action of the calf muscle contracts and squeezes the deep veins, opening the valves and forcing the blood back towards the heart. This is particularly important because when you are standing the blood has to travel a long way against gravity back to your heart.
How does the lymphatic system work?
The lymphatic system is crucial in maintaining the body’s fluid balance, carrying excessive fluid, fats from the digestive system and proteins that have leaked from the capillaries back to the general circulation. If this did not happen the excess fluid would accumulate in the tissues as oedema (Starr et al, 2008).
Fluid circulating in the lymphatic system is called lymph and is crucial to your immune system, carrying foreign particles and cellular debris to the lymph nodes (Starr et al, 2008). Lymph capillaries are seen in the tissues of all the body’s organs, where extracellular fluid is simply absorbed through the capillary walls (Starr, 2008). Like veins, lymph vessels also have flap-like valves that prevent backflow — breathing and muscle movement helps to move lymph fluid through the system.
Lymph nodes are found at intervals along a lymph vessel and specialist cells (macrophages) help to clear the lymph of bacteria, debris and other substances as it passes through. Lymph vessels converge into ducts that drain into the veins in the lower neck where the clean lymph fluid is returned to the circulation (Starr et al, 2008).
How do the venous and lymphatic systems work together?
As blood passes through the capillaries some fluid leaks out through the semi-permeable walls and into what is called the interstitial space — the area that lies between the capillary wall and the tissues. This fluid is known as interstitial fluid and is where the exchange of nutrients, waste, electrolytes, and proteins between the vascular and lymphatic systems and tissue cells takes place.
When the venous and lymphatic systems are working together properly, the flow of fluid between the tissues, blood and lymphatic systems is balanced — when disease is present, however, excess fluid collects and causes oedema.
Why do skin changes occur with venous and lymphovenous disease?
Sometimes a patient’s veins can be damaged through surgery or trauma, or simply do not work correctly because of disease. When this happens, blood will flow back down into the veins leading to an increase in blood volume and pressure (venous insufficiency), causing fluid, red cells and protein to leak from the capillaries into the tissues. This causes some of the skin changes seen in venous and lymphovenous disease, such as hyperpigmentation and oedema. If the problem is not treated, inflammation in the tissue will result in further skin symptoms including varicose eczema and lipodermatosclerosis (inflammation of the layer of fat under the epidermis).
The increased volume of blood in the veins also means that they become stretched and the valves are unable to prevent a backflow of blood, resulting in more fluid leaking out into the tissues. Stretching of the veins also leads to their becoming varicose and the lymphatic system is then unable to cope with the extra fluid, causing more oedema and chronic high blood pressure in the vein (venous hypertension). These are the main underlying causes of venous leg ulceration and lymphovenous oedema.
The resulting severe skin changes, such as leg ulceration and swollen or wet leaky legs, can have a huge negative impact upon a patient’s quality of life, leading to social isolation and depression (Persoon et al, 2004; Jones, 2008). These symptoms also risk the patient developing complications, including cellulitis (Anderson, 2006; 2008), potentially resulting in admission to hospital.
However, these symptoms of venous and/or lymphatic disease do not occur out of the blue, but start out as mild skin changes that can become worse with time if the underlying failure of the venous and lymphatic systems is not spotted. However, if these skin changes are recognised as an indication that the venous and lymphatic systems are not working properly, further assessment of the patient will allow you to implement a management that will prevent the condition from worsening.
Using a toolkit to help you identify skin changes
In any area of care it is important to use the tools at your disposal to provide the best care for your patients. The CHROSS Checker is a toolkit consisting of an assessment chart and key cards that have been developed to help you easily identify the skin changes that occur as a result of underlying venous and lymphovenous disease, when carrying out holistic patient assessment.
As well as helping you to identify skin changes, the toolkit also provides clear guidance on which compression products can be used to manage the disease type and severity of skin change. For clinicians unfamiliar with some or all of the signs and symptoms listed on the CHROSS Checker chart, the key cards contain further information in the form of a photograph, definition and cause of each sign and symptom listed.
The CHROSS Checker chart provides you with an easy three-step approach to identifying signs of venous/lymphatic disease during skin assessment, and helps you to select an appropriate compression product to manage the limb(s), according to disease severity, as part of an overall care plan.
The CHROSS Checker should be used as part of a holistic patient assessment, to raise awareness and detection of skin changes on the lower limb. You can use it while assessing any patient to identify the early signs of venous disease, the worsening of skin changes, or for advanced skin changes and severe symptoms presented for the first time. Even the most severe skin changes can be improved through correct management, so it is never too late to identify them and intervene.
When using the CHROSS Checker in conjunction with holistic patient assessment, you can systematically examine the limb for skin changes and implement treatment if appropriate.
Why use compression to manage skin changes?
Compression therapy is a key component of managing venous and lymphovenous disease (Hardy, 2010). It enhances the functioning of the calf muscle pump and also helps to close faulty veins on calf muscle relaxation, preventing the backflow of blood. As a result, it improves venous return and helps to redistribute blood and fluid from the lower limb back into the central sections of the body, reducing venous congestion and blood pressure (Torra i Bou and Moffatt, 2008).
Compression relieves the symptoms of venous and lymphovenous disease and accelerates the healing rate of venous ulcers, improving the patient’s general skin condition (Moffatt, 2007). Compression also improves lymphatic flow and re-absorption of lymph into the lymphatic system (Foldi et al, 2006).
In patients with chronic oedema, and/or leg ulceration, you can use compression bandaging (most commonly cohesive short-stretch [inelastic]) to reduce limb volume and promote healing. Once limb volume has reduced and/or ulceration healed, compression hosiery is commonly continued to maintain limb volume and shape, and to prevent ulcers from re-occurring (Hardy, 2006). If hosiery is not continued after an initial period of intensive therapy, any improvements may be lost (Timmons and Bianchi, 2008). Made-to-measure compression products are available or patients whose limbs do not fit standard sizes.
What type of compression hosiery should you use?
There is a wide range of compression hosiery garments available, which can be used at all stages of venous and lymphatic disease development. For patients with early stage skin changes and no oedema that require preventive treatment, the use of British Standard hosiery is appropriate. British Standard hosiery is more cosmetically acceptable with lighter yarns, many different styles, patterns and colours available to help with patient concordance (Timmons and Bianchi, 2008).
If a patient is diagnosed with oedema, the first step is to reduce the limb volume using bandaging. Then European Class hosiery garments can be used to prevent recurrence or deterioration. The action of European Class garments with a stiffer profile are more likely to encourage lymphatic movement, reabsorption of the lymph and reduction of oedema due to their greater stiffness, which comes from the yarns and the knitting process used in the manufacture (Timmons and Bianchi, 2008). Patients with limbs that are severely swollen may not fit into standard hosiery sizes and will require made to measure garments. These are usually constructed using thicker and firmer material that helps to effectively contain the limb.
For all patients with venous or lymphovenous disease, you should use compression as part of an overall treatment plan which, depending on the underlying medical condition and skin changes present, may consist of medical management, skin and wound care, exercise, manual lymphatic drainage (MLD) and patient education.
Using knowledge to help your patients
If left untreated venous and lymphovenous disease can cause severe skin problems, including leg ulcers and cellulitis. Understanding the signs of venous and lymphovenous disease and looking for them during skin/wound assessment means that you will be able to provide your patients with appropriate intervention, stopping the disease from progressing and improving symptoms.
Awareness and early intervention using a care plan that addresses the underlying disease, skin care and compression, can halt or slow disease progression, thereby allowing you to reduce costs and help to improve the quality of life of your patients.
Progressive disease is not only bad for your patients, it is also costly — advanced signs and symptoms such as cellulitis are linked with hospital admissions, costly bed days and increased risk of further episodes.
Using the available resources, such as the CHROSS Checker tool kit, will provide you with a quick and easy way to evaluate skin changes as part of holistic patient assessment, and give you clear guidance on the selection of compression products to delay disease progression in patients with venous and lymphovenous dysfunction.
Like in any other area of care, understanding the skin changes affecting your patients’ lower limbs and having confidence in what steps to take will help you prevent a drama becoming a crisis.
Anderson I (2006) Aetiology, assessment and management of leg ulcers. Wound Essentials 1: 20–37
Anderson I (2008) Understanding chronic venous hypertension. Wound Essentials 3: 20–32
Foldi E, Junger M, Partsch H (2006) The science of lymphoedema bandaging. In: European Wound Management Association (EWMA). Focus Document: Lymphoedema bandaging in practice. London: MEP Ltd: 2–4
Hardy D (2006) Managing long-term conditions, non cancer-related lymphoedema. Br J Nurs 15(8): 444–52
Hardy D (2010) Chronic oedema and associated complications. Wounds UK 6(4): 138–45
Jones JE, Barr W, Robinson J (2008) Impact of exudate and odour from chronic venous leg ulceration. Nurs Stand 22(45): 53–61
Koeppen BM, Stanton BA (eds) (2010) The cardiovascular system. In: Berne and Levy Physiology. Mosby Elsevier, Philadelphia: 287–415
Moffatt C (2007) Bandaging and compression therapy. In: Moffatt C, Martin R, Smithdale R (2007) Leg Ulcer Management. Blackwell Publishing, Oxford
Persoon A, Heinen MM, van der Vleuten CJ, de Rooij MJ, van de Kerkhof PC, van Achterberg T (2004) Leg ulcers: a review of their impact on daily life. J Clin Nurs 13(3): 341–4
Starr C, Taggart R, Evers C, Starr L (2008) Circulation. In: Biology: The Unity and Diversity of Life. Brooke Cole, Belmont: 287–415
Timmons J, Bianchi J (2008) Disease progression in venous and lymphovenous disease: the need for early identification and management. Wounds UK 4(3): 59–71
Torra i bou JE, Moffatt C (2008) Understanding compression therapy. In: Leg Ulcers and Problems of the Lower Limb: An Holistic Approach. Wounds UK, Aberdeen