Topical skin cooling for lymphedema is effective in reducing tissue pressure.

People living with lymphedema know that managing lymphedema often requires daily care. Most people keep their lymphedema in check with a combination of treatments that include lymphatic drainage massage, bandaging, compression garments or compression wraps. Daily stretches and exercises to utilize the natural muscle pumping action are also helpful and it is advisable to create an individualized exercise program with a trained lymphedema therapist. Especially in the summer, when temperatures are warmer, persons living with lymphedema are well aware that managing swelling requires diligence. It is well known that warmer temperatures tend to increase metabolism and the production of lymphedema.

The mission of the NPO South Florida Breast Cancer Rehab Center is to improve the lives of women and men living with lymphedema. Our commitment includes initiating and participating in research for the purpose of improving treatment options available to the lymphedema community. For the past 10 years we have been experimenting with topical skin cooling as an adjunct in the management of lymphedema. July of 2016 saw the conclusion of our first research study titled: Local Skin Cooling as an Aid to the Management of Patients with breast Cancer related Lymphedema and Fibrosis of the Arm and Breast. This study was approved by the Institutional Review Board at NOVA South Eastern University. The study was directed by Dr. Harvey Mayrovitz PHD, who is well-known for his contributions to research studies in the field of lymphedema. The concept and vision for cooling came from Jean Yzer, PT-CLT, LANA who saw the clinical potential and pursued a scientific path to gather data and bring the findings to the attention of other clinicians in the frontline of providing care to patients living with lymphedema. The data for the study was collected from 32 brave and generous women with an active diagnosis of breast cancer related lymphedema of the breast and upper extremity. These women have one selfless declared desire: That they might be able to help other women living with lymphedema by the outcome of this study.

The study quantified what we have seen by clinical observation and known anecdotally: Topical skin cooling softens tissue pressure by up to 28 % during a treatment session. Topical cooling also bring a host of other benefits such as decreasing inflammation, decreasing pain and allows for better fibrosis management. Due to the ease of application, low cost and ease of availability topical cooling of lymphedematous tissue may well deserve a spot as a first ranked treatment option for anyone suffering from lymphedema of the arm and breast.

Though we have utilized topical skin cooling at our clinic with patients with lymphedema of the lower extremities, and though we have collected some data, we have not yet published a scientific study. Clinical observation and anecdotal evidence are overwhelming that all secondary lymphedema responds to topical skin cooling and by reducing tissue pressure and that topical skin cooling also aids in resolving lymphedema related fibrosis of tissue. The impact of cooling has not yet been studied in primary lymphedema or in lipolymphedema.

The next obvious question is, what is the protocol for topical cooling of lymphedema? The following is a description of the protocol for cooling utilized in the study. It is reproduced here for the purpose of sharing information with professional peers. This method is not recommended for home use or patient self-treatment unless instructed by a trained lymphedema specialist.

In the study we utilized a mixture of ice and water. Patients who have undergone a surgical procedure may have altered sensation at the site of the lymphedema. This is not a contraindication for cooling since the temperature of the ice water mixture should never fall below freezing where microvasculature could incur permanent damage. We immersed washcloths into the cold bath and wrung them out. Upon patient testing by touch and patient approval the cool cloths were laid over the lymphedematous body part, making sure to make good contact with the skin.   The cloths were left in place until they warmed up. This will differ by person depending on the level of lymphedema present. Do not be alarmed if the towel warms up quickly. It is a commonly known fact that areas with lymphedema are generally warmer in temperature, as body fluid retains heat. Since there is a buildup of fluid in the area with lymphedema it is likely that the area under the skin will be warmer. Sometimes the temperature difference is not measurable on the skin to a skin thermometer but the temperature can be warmer under the skin where the lymphedema is present. The warmer the tissue under the skin, the faster the cold washcloth towel will warm up. The fact that fluid collection under the skin tends to hold heat will explain why cellulitis infections can develop in areas with lymphedema as bacteria that may enter the skin through cuts and abrasions can grow faster in the warmer cellular milieu.

The cooling process was repeated till the wash cloths no longer became warm when applied to the skin. On average this required 4-5 applications and a time period of 12-15 minutes to achieve. Average decrease in skin temperature between pre- and post-cooling temperatures was approx 45 degrees F. Palpation will reveal that the reduction in temperature will be accompanied by a softening of the tissue. Clinically the softening of the tissue is beneficial to the lymphedema specialist who will be able to palpate the contour of any fibrotic patches under the skin. The therapist can now focus the fibrosis techniques. Decreases in nerve pain related to nerve compression as is seen in lymphedema occurred rapidly with cooling as the superficial sensory nerves were impacted. Having achieved the desired cooling and analgesic effect, the therapist can now proceed with the treatment.

This method though highly effective for a trained clinician for treating patients with lymphedema and fibrosis is not recommended for patients in the home since the grade of temperature change may be difficult to assess without supervision. Ice burns are highly unlikely since freezing temperatures were never applied to the skin in the protocol for topical cooling utilized in the study. Possible negative effects of applying ice or frozen objects directly on the skin could be burns, lasting redness, or painful small vessel spasms. We had no incidents of burns during our study. If the patient stated that the washcloth was too cold, the temperature of the water was warmed by applying room temperature water. Utilizing ice water as a home cooling method is also discouraged as it is messy and sheets and flooring are likely to get wet, encouraging other injuries such as slipping in puddles.

An effective and safe treatment option for home topical skin cooling is in progress.