“Informed patients know that lipedema hurts”

The fact that when addressing a case history, one should act unobtrusively in order to see whether a pinch actually triggers pain is something Dr. med. Gabriele Faerber from the Center for Vascular Medicine in Hamburg (Germany) knows from her own experience. In the following interview with Bauerfeind life, she also talks about the things a physician has to pay attention to when diagnosing and treating lipedema and lymphedema.

Bauerfeind life: Cases of swollen legs require a differential diagnosis. What is your approach in such situations?
Dr. Faerber: A clinical diagnosis generally achieves the objective, and an additional examination with medical apparatus is only rarely necessary. After putting together a very extensive case history that includes, among other things, the point in time when initial symptoms occurred, as well as the patient’s weight and family medical histories, we take a close look at the patient to determine whether there is swelling in both legs, for example.
Lipedema is always symmetrical , while an asymmetric pattern indicates lymphedema. If swelling occurs in both legs, we need to determine whether the pattern is truly symmetrical or if one leg is leading, so to speak. If the latter is the case, we might once again be dealing with lymphedema. After describing the findings and taking comparative circumference measurements, we check to see whether the skin is soft or if fibrosis is already present. We also check the Stemmer’s sign. With lipedema, a skin fold can be lifted at the back of the second toe, whereas with lymphedema, the skin and the subcutaneous area are so “baked” that no skin fold can be lifted anymore. On the other hand, the Stemmer’s sign doesn’t necessarily have to be present in the case of obesity-related lymphedema. Lymphedema is also indicated by excessive cornification of the skin and folds on the MTP joint that give the impression of a thickened toe. In the case of lipedema, the excessive fat deposits end above the wrist and ankle. On the foot , this is referred to as the “Suaven Phenomenon” or a “supramalleolar sudden change in diameter.”
Unlike the case with lipedema, there is no pressure pain or swelling tendency with lipohypertrophy. “Dr. Google” makes a diagnosis more difficult here because these days informed patients know that lipedema hurts. We therefore need to be as unobtrusive as possible when we attempt to determine whether a pinch actually triggers pain, for example.

What do you do if diagnoses are mixed?
Dr. Faerber: The mixed forms and fluid transitions in particular make it difficult to differentiate. For example, lipohypertrophy can turn into lipedema. This often happens when a patient gains weight , if hormonal changes occur, or if estrogen dominance is present. A hormonal imbalance can either lead to a significant worsening of lipedema in terms of both volume and symptoms, or else it will trigger lipedema where none was previously present.
However, developments can move in the opposite direction if a certain nutritional treatment program is undertaken. For example, more than 80 percent of our patients transition from lipedema back to lipohypertrophy after changing their diet and/or losing weight. These patients no longer display a swelling tendency, feel much less or even no pain at all , and often no longer require lymphatic drainage. A further diagnostic challenge involves adiposity, which can also conceal a disproportion, for example.

How do you treat individual conditions?
Dr. Faerber: In the case of a thin lipedema patient , we start with compression therapy. This doesn’t necessarily have to involve flat knit care; if the patient’s leg shape is largely normal , round-knit compression with the requisite stiffness is often sufficient. We now try not to start immediately with an accompanying lymph drainage, which is in fact a questionable choice of treatment for pure lipedema. If compression alone does not provide sufficient relief, we run a short phase of lymph drainage, but only as an introductory rather than a long-term treatment. In general , we also recommend a lot of movement and a diet consisting mainly of basic foods and less rapidly digested carbohydrates. I consider patients whose condition does not improve as a result to be suitable candidates for liposuction. The more pronounced the disproportion, the more suitable will be such a treatment.

We also start with compression in the case of overweight patients. If adiposity or changes to the shape of the legs become advanced, we can usually only use a flat knit product , possibly – as with lymphedema in such situations – with a divided treatment. Very obese women will have problems putting on stockings, which is why we prescribe Capri pants with knee-high stockings, for example. It’s actually the shape of round-knit stockings, rather than the leg swelling tendency, that make such stockings problematic. In the case of obese women, we often face a major problem in terms of mixed conditions, such as lipedema with adiposity and a secondary lymphedema caused by the adiposity. We have to explain all this to the patients – for example that they will not be able to eliminate pure lipedema by changing their diet; the predisposition will remain. However, an accompanying lymphedema can be effectively influenced if the adiposity can be reduced. Naturally, lymph drainage is also indicated for lymphedema. However, it makes no sense to only prescribe a lymph drainage if the actual cause is adiposity.

What else does the guideline recommend for treating lipedema?
Dr. Faerber: In the case of accompanying excess weight or adiposity, the guideline calls for nutritional therapy, behavioral therapy, and exercise. Aqua cycling has proved to be a great sport in this regard. I don’t want to give the impression here that one can solve the problem simply by changing their diet and becoming more physically active – a notion that many lipedema patients rightly reject Nevertheless, both aspects should be systematically pursued in order to prevent further deterioration.

Images: Andreas Wetzel , Dr. Gabriele Faerber, Bauerfeind