Chapter: Consultation hour
Article: 3 of 12
Update: Feb 24, 2021
Author(s): Wohlgemuth, Walter A.
Recurrent bacterial inflammation of the skin and subcutaneous tissue (erysipelas), which spreads via the lymphatic system (lymphangitis), occurs mainly in patients with lymphedema and superficial lymphatic malformations. Patients with lymphangioma circumscriptum or lymphatic vesicles on the skin are at highest risk of erysipelas. In these cases the bacterial barrier function of the skin is disturbed.
Erysipelas manifest themselves as local extensive skin redness and warmness of the skin, local pain in the area of the inflammation and possibly fever as an additional sign of a systemic reaction. Very rapid evolution to a systemic, dangerous inflammation with a general feeling of inflammation (feeling of warmth, muscle, joint and limb pain, rapid heart rate, sweating) is possible, especially in patients with lymphatic malformations.
Skin areas from which lymphatic fluid leaks (lymphorrhea) are particularly at risk because the skin has largely lost its natural function as a barrier against the penetration of bacteria. Lymphorrhea occurs mainly in the lower extremities, as the hydrostatic pressure is highest there and the lymph is thus pressed more easily through the skin.
Skin injuries in the area of an affected lymphedematous extremity, whether due to trauma, scratching, surgery, intervention or laser treatment, are also particularly at risk of infection and erysipelas. Sometimes medical prophylaxis even has to be carried out before or during the procedure. In the case of a lymphatic malformation in the oral cavity (cheek, tongue, palate), strict dental and oral hygiene must be observed.
Chronic, non-healing wounds in patients with arteriovenous malformations also represent an important source of bacterial infection. These must be treated with particular care, as they heal with difficulty, often become superinfected and may even bleed considerably owing to the underlying arteriovenous shunt connections (arterial pressure).
These skin areas at risk of infection are always located in the same or similar regions where the malformation is located. This allows the patient and physician to find out which areas require special protection, care and disinfection.
First and foremost, it is important to avoid skin injuries in these vulnerable areas. Special clothing or compression garments offer particular protection for this purpose. Appropriate, individually tailored, very well fitting individual compression garments are absolutely necessary. Poorly fitting compression garments, e.g., at the suture seams or at the back of the knee or instep, lead to localized, severe, additional mechanical strain on the skin. If necessary, poorly fitting garments must be resized, otherwise they will do more harm than good.
The skin must not be too dry or chronically too moist, and good skin care must be ensured. In areas particularly prone to erysipelas, washing once a day with a disinfectant soap may be indicated. In the case of recurrent erysipelas on the foot, a daily disinfectant, prophylactic foot bath is also necessary.
Lymphatic malformations of the neck and face, which often also have connections to the jaw bones and tongue, are a special case. In addition to good oral hygiene, good dental hygiene is particularly important in this situation. Caries and chronic periodontitis can lead to jaw and cervical abscesses, which, in conjunction with a lymphatic malformation, can also form massive intraosseous abscesses.
The interdigital spaces between the toes as well as toenails are particularly at risk of chronic infections in the presence of lymphorrhea and simultaneous soft tissue hyperplasia with ingrown toenails. Care must be taken to keep the skin clean, especially the hard-to-reach areas of skin on the foot, particularly when cutting toenails.
When skin injuries occur, which can never be completely avoided, it is essential to ensure antisepsis and cleanliness. First, antisepsis with a disinfectant liquid preparation for superficial wounds. Then cover the wound with a plaster, if necessary with a sterile dressing as well. Seek medical attention in good time. For more detailed information on the treatment of wounds, see separate chapter.
Erysipelas prophylaxis with antibiotics may be necessary if more than 3 erysipelas occur in one year, if there are several erysipelas in a row or recurrently, or in the case of severe erysipelas or lymphangitis.