Lymphoedema

The Lymphoedema Service at the Royal Cornwall Hospital, provides specialist assessment and treatment for children and adults with lymphoedema of any cause, and women with lipoedema. We accept patients from any part of Cornwall and the Isles of Scilly.

Lymphoedema Support during the Covid 19 Pandemic

The Lymphoedema Clinic is no longer offering face-to-face outpatient appointments during the Covid 19 pandemic. We will however be offering a telephone and video clinic for urgent patients once a week and will also offer limited telephone and email advice during this time.

Please email rch-tr.lymphoedema@nhs.net or telephone 01872 252601 and leave a message for the Lymphoedema Team. Messages will be triaged and responded to as able.

The Lymphoedema Service is based in the Therapy Department, at the Royal Cornwall Hospital in Truro. We are currently unable to offer this service elsewhere in Cornwall. The service is provided by experienced Heathcare Professionals with specialist qualifications in lymphoedema management, with the support of a Lymphoedema Technician.We will see patients with oedema that has been present for more than three months or is related to cancer and its treatment. This includes:

Primary lymphoedema

Due to the underdevelopment or failure of the lymphatic system. It may develop without any obvious cause at different stages in life, but particularly in adolescence and during the menopause.

Secondary lymphoedema

As the result of some problem outside of the lymphatic system that prevents it working properly such as cancer and treatment for cancer, surgery, injury or infection, reduced mobility / paralysis, obesity and problems with veins such as varicose veins.

Lipoedema

An adipose tissue disorder that is characterised by abnormal fat deposition of the lower limbs and tenderness.

For more information on lymphoedema, you may find this short video useful.

Information for Healthcare Professionals

Due to limited outpatient services at present the following information is to support Community staff to care for patients within their own homes. The Lymphoedema clinic will be providing an email, telephone and video clinic at least once a week to support community staff and patients. Please email rch-tr.lymphoedema@nhs.net.

Compression wraps
Compression wraps are commonly used to treat leg lymphoedema. They are adjustable and can accommodate a wide range of measurements. Most can also be trimmed to reduce the size of the garment as the oedema reduces therefore prolonging the use of the garment. They should be used over a liner or yellow line and dressings should be used to control exudate where needed. There are a number of compression wraps on the market the most commonly used in Cornwall are the Juzo ACS, the Juzo 6000 and the Medi Juxta-fit. They are all available on FP10. Instructions on how to measure for them, fit them (including videos) and care for them are on the links below:

Juzo ACS Wraps
https://www.juzo.com/en-uk/products/compression-garments/compression-therapy/special-products/juzo-acs

Juzo 6000
https://www.juzo.com/en-uk/products/compression-garments/compression-therapy/lower-limb/juzo-compression-wrap

Additional Velcro can be ordered for Juzo wraps should the Velcro become damaged or worn out.

Medi Juxta-Fit wrap
https://www.mediuk.co.uk/shop/juxta-fit-lower-legging.html

Toecaps
Toecaps can be used with compression bandaging to reduce toe and base of toe oedema. The following toecaps are trim to fit so the toes can be reduced in length. They can be washed by the patient and reused. They are both available on FP10.

Haddenham Healthcare Microfine toecap
Available in 20-36 mmHg
https://hadhealth.com/microfine-toecap

Juzo Classic Seamless Toecap
Available in Class 1 and Class 2
https://www.juzo.com/en-uk/products/compression-garments/compression-therapy/upper-limb/juzo-classic-seamless

Covid 19 information for patients with Lymphoedema or Lipoedema

How we can help

Following assessment we are able to provide a range of treatments tailored to the individual patient, alongside self-management techniques. Our aim is to improve the lymphoedema and help patients to understand their condition and learn how to manage it themselves.

Treatments may include:

  • Skin care
  • Exercise
  • Weight management
  • Compression garments
  • Multi- layer lymphoedema bandaging – to improve the shape and size of severe swelling
  • Simple lymphatic drainage ‐ a skin moving technique similar to massage
  • Manual lymphatic drainage ‐ a more intense specialist massage technique
  • Kinesio Taping
  • Intermittent Pneumatic Compression therapy

What to expect at your first appointment

Your initial appointment will be between one and two hours. You will be seen by one of the Lymphoedema Clinicians who will assess you and aim to give a diagnosis. You will be asked to undress so that the therapist can examine both the swollen and the adjoining area.

You may be asked to get onto a couch to enable the therapist to assess you. If you have difficulty getting in and out of a chair or bed, or need special equipment to help you, please let the clinic know before you come to your appointment.

If you think you would like someone else to be present, you are welcome to bring a friend, family member or carer or ask us to provide a chaperone for you.

At the end of your initial assessment we will agree a treatment plan. We’ll rarely start treatment at this initial appointment and you’ll need to return to the clinic for further appointments.

Directions to the Lymphoedema Unit

The Lymphoedema Unit is in the Therapy Department on the second floor of the Princess Alexandra Wing (Maternity) at the Royal Cornwall Hospital in Truro. When you arrive at hospital, follow the signs to the Princess Alexandra Wing. The Therapy Department is on the second floor.

Find out more about coming to the Royal Cornwall Hospital

Referrals to the Lymphoedema Service

We accept referrals from any healthcare professional with the agreement of the patient’s GP. For further information please see the Referral and Discharge policy.

The Management of Cellulitis in Lymphoedema

What is Cellulitis?

If you have lymphoedema, the build-up of fluid in your tissues makes you more vulnerable to infection and your lymphatic system, in the affected area, does not function adequately to fight infection. Cellulitis is a bacterial infection of the deep layer of skin (dermis) that often affects people with lymphoedema. Cellulitis can also sometimes cause lymphoedema.
Symptoms of cellulitis can include:

  • redness and a feeling of heat in the skin
  • pain and increased swelling in the affected area or in the armpit or groin
  • a high temperature (fever) or chills
  • flu like symptoms

What should I do if I develop cellulitis?

Contact your doctor immediately as you will need antibiotic treatment. For information on the type of antibiotics used in the treatment of cellulitis in lymphoedema, see the Cellulitis Consensus Document. You can take this to your GP to help them to treat you.

Discharge Information for Patients and Healthcare Professionals

Lymphoedema Service – Following discharge from the Lymphoedema Clinic (RCHT1693)

Repeat Prescription Guidance

Following discharge from The Lymphoedema Clinic the patient will need to request their compression garments prescribed by their GP annually. A prescription letter will be sent to the Patient’s GP and a copy to the patient. This letter will give full details of the patient’s hosiery prescription and when the repeat date is due. Each year the patient can request a repeat prescription from their GP which will be fulfilled by their Pharmacy or an online prescription service. If the Pharmacy has a query or any problems getting the correct garment they should contact the supplier who will be able to assist.

Made to measure Garments

If the prescription is for a ’Made to Measure garment’, a size or measurements are not required. Please quote the Order Reference number as shown in the discharge letter and the company will make the repeat garment, to the same size as previously ordered. The Order Reference number is unique to the patient. Prescriptions for made to measure hosiery can be fulfilled by the pharmacy in the usual way or using an on-line prescription service as shown below.

Sigvaris Group

Sigvaris Group have changed the names of some of their products. Therefore from 1st January 2020 they have set up a support line for any Sigvaris issues with products and ordering. Please contact 01264 326666 Option 0.

JOBST – Bellavar

From 1st May 2020 JOBST Bellavar will be replaced and re-named as JOBST Classic on drug tariff. If you have any patients currently in JOBST Bellavar you will need to switch their next order to JOBST Classic. Please contact the supplier on 0845 1223600 who will be able to supply you with the code changes and offer advice for prescription requests.

Prescription services:

Online pharmacy services offer a free compression garment, prescription delivery service for patients, this service is free of charge but prescription charges will apply. Prepaid envelopes can be obtained from the companies. Examples of these services are:

Daylong

www.daylong.co.uk Tel 0800 195 0160

Patient Choice

www.patientchoice.net/  Tel 0800 862 0686

For Essity / Jobst garments only

www.bsnmedical.co.uk Tel 0845 1223600

For Medi garments only

enquiries@mediuk.co.uk  Tel 01432 373500

Items not on FP10 Prescription

Occasionally due to complex clinical need patients are discharged with items that are not available on FP10 prescription. The prescriber will need to request the item from the RCHT Appliance Office annually, quoting the Order reference shown in the prescription letter.  The Appliance Office will then order the items and send to the patient directly.

Prescribers should email the request to rch-tr.ApplianceOrder@nhs.net

Prescription Charges for Compression Garments

Unless you are exempt from prescription charges or have a pre-paid prescription certificate you will need to pay a prescription charge for your compression garment.

Your pharmacy will advise how much this is and whether a pre-paid certificate is more cost effective.

As a general rule you should be charged one prescription charge for each type of item i.e. if you have four pairs of identical stockings then this would be one prescription charge, however if you have two pairs of black and two pairs of beige then this would be two prescription charges.

Measuring patients for a repeat prescription

Patients discharged with a hosiery prescription will have been stable for some time. We would therefore not expect them to need to be re-measured for compression hosiery as they should remain within the tolerance of the hosiery. If the patient is not reporting any problems with their compression hosiery then a repeat prescription can be made. However if the patient’s weight or lymphoedema has changed significantly or they report issues with their hosiery it would be prudent to check that they still fit within the hosiery prescribed. If the patient reports weight loss or gain then they should just require a different size. If the patient feels their condition has become worse than they should be re-referred back to the lymphoedema clinic

Measuring for Leg hosiery

As a rule, the following circumferences should be checked:

  • B above the malleolus
  • C widest part of calf
  • D Below knee or G top of leg

Measuring Toecaps

  •  A Base of toes

Measuring for Arms garments

As a rule, the following circumferences should be checked:

Hand

  • A Base of the MCP joints

Arm

  • C Wrist
  • E Elbow
  • G Top of arm

 

Sizing Charts

The sizing charts for the hosiery are all available online and can be found on the links below.

Essity (formerly BSN)

https://www.bsnmedical.co.uk/bsn-medical-uk.html

Juzo

https://www.juzo.com/en-uk

L&R (formerly Activa)

https://lohmann-rauscher.co.uk/

Medi

https://www.mediuk.co.uk/products/

Sigvaris

https://www.sigvaris.com/uk/en-uk/productsearch/product_line/sigvaris-medical

Haddenham Healthcare

https://hadheath.com

 

Made to Measure Garments

The patient will be discharged with a well-fitting garment that they have been stable in for some time. The measurements should therefore not need to be changed. However if the patient’s weight or lymphoedema has changed significantly or they report issues with their hosiery it would be prudent to check that they still fit within the hosiery prescribed. If the patient reports weight loss or gain then they should just require a different size. If the patient feels their condition has deteriorated, please submit a new referral to the Lymphoedema Clinic.

To obtain the measurements for the patient you will need to contact the company and ask for the measurement form. There is a 2cm tolerance in the hosiery up or down (i.e. the patient can be 2 cm smaller or larger and the garment will still fit).

Vascular Assessment and Lymphoedema

We recommend that patients with lymphoedema, who are wearing compression garments, should have, as a minimum, an annual vascular assessment. We do not recommend Ankle Brachial Pressure Indices (ABPI) in the presence of oedema, obesity and hyperkeratosis, as the results can be falsely elevated.

A full clinical assessment of risk factors and presenting symptoms is needed; pedal pulses may also be needed depending on the age and health of the patient.

 

For further information about vascular assessment in lymphoedema please see the following documents:

The British Lymphology Society

Position paper for Ankle Brachial Pressure Index (ABPI)

Informing decision making prior to the application of compression therapy

https://thebls.com/public/uploads/documents/document-20621539855354.pdf

The British Lymphology Society

Vascular Assessment Tool

https://thebls.com/public/uploads/documents/document-52961539855306.pdf

Further sources of information on Lymphoedema and Lipoedema

Cornwall Lymphoedema and Lipoedema Patient Support Group

CLLASS Cornwall Lymphoedema and Lipoedema for Activity, Social Support

The aims of CLLASS are supporting one another, fundraising, socialising and education. For further information please visit the website http://cllass.org.uk/ or contact info@cllass.org.uk