There's More Than One Way to Treat Lipedema

A 34-year-old woman presented to a hospital with an excessive accumulation of fat in the subcutaneous tissue of her legs. She said she had a long history of dealing with a "stubborn constitution" and that she had first gained weight soon after she began menstruating.

She noted that her legs had thickened during her teens, despite having a very active lifestyle. Through diet and exercise, she managed to lose weight in the trunk of her body, but her lower limbs remained essentially unchanged. At her heaviest, she said, she had weighed 95 kg (about 209 lbs). After losing weight, she was about 65 kg (143 lbs), but the volume of her legs stayed the same.

Clinicians performed a physical examination, which found no evidence of Godet or Stemmer signs. However, deposition of fat in the patient's lower limbs was tender to palpation, and her score on the Lipedema Symptom Assessment Questionnaire (QuASiL), which the case authors developed, was 115 points out of 150 (with 0 representing no symptoms and 150 indicating the presence of all symptoms, and the highest impact on quality of life).

Superficial and deep-color Doppler ultrasound of the lower limbs revealed small varicosities in the thighs and legs, without significant reflux. Dermal thickness was 22.4 mm in the right pre-tibial region and 21.2 mm in the left pre-tibial region.

Bioimpedance examination found a BMI of 34.2, body fat percentage of 41.6%, and lower-limb volume of 572.21 mL. Clinicians diagnosed the patient with grade III lipedema.

Though surgical treatment with tumescent liposuction appeared to be indicated, the patient requested clinical treatment, which included an anti-inflammatory diet followed by a ketogenic diet along with regular aquatic physical exercise, manual lymphatic drainage, and antioxidant herbal medicines.

Improvements over 11 months in QuASiL scores and lower-limb volume loss were as follows:

• After 1 month: score of 107 (6.9% improvement), volume loss of 3,972 mL

• After 3 months: 86 (25%), 6,472 mL

• After 6 months: 76 (34%), 6,346 mL

• After 11 months: 59 (49%), 740 mL

At 12 months post-diagnosis, her final lower limb volume decreased from a baseline of 32,572.21 mL to 21,832 mL.

Discussion

Clinicians presenting a case series of five patients with lipedema noted the importance of individualizing treatment to consider each patient's particular technical limitations and clinical characteristics. Liposuction surgery should be considered a possible, but not the only, treatment, but non-surgical treatment is feasible in selected cases, and can meet the criteria for achieving selected clinical objectives, the authors explained.

The case series described successful clinical treatment of five women diagnosed at various stages of lipedema, all with different symptoms -- i.e., persistent bruising and pain, pain and fat deposition, night cramps and discomfort, leg thickening, and redness in the legs -- as well as their treatment goals.

The focus for this case report is on Patient 4, with stage III lipedema, which the authors noted is generally "characterized by hardening and thickening of the subcutaneous tissue with large nodules and protrusion of cushions/accumulations of fat, especially in the thighs and around the knees."

She had grade I obesity on the basis of BMI, with substantial fat deposition in the lower limbs. In this case, the authors said, the lipedema mimicked obesity, although there was still significant volumetric decrease in addition to symptomatic improvement.

The inherited, chronic, progressive disease of lipedema is characterized by the abnormal accumulation of fat in subcutaneous tissue, mainly in the lower and upper limbs, which can have a destructive effect on quality of life, due to the associated risks of deformity, mobility limitation, and damage to the lymphatic vascular system, the authors stated. Females are most commonly affected.

Lipedema is often confused with lymphedema, or misdiagnosed as obesity or chronic venous disease (which can occur concomitantly with lipedema), and stage IV lipedema is indeed associated with lymphedema and is also called lipolymphedema, the team explained.

When lipedema is in its intense inflammatory phase, patients may present with pain, sensitivity to touch, swelling, chronic fatigue, and unprovoked ecchymosis. The following are the typical signs of lipedema:

• Disproportionately increased limb volume

• Adipose tissue on the limbs

• Symmetric tissue

• Palpable tissue nodules

• Painful tissue (although not always)

• Limb swelling (pitting or non-pitting), sparing the hands and feet

The authors of a 2018 review about the differences between lipedema and lymphedema observed that lipedema's striking clinical features, filling of retromalleolar sulci with fat, and pressure sensitivity of the below-knee medial fat pad can help with diagnosis when clinicians are familiar with the disease, and can distinguish it from obesity and lymphedema.

In particular, that review noted that in lipedema, enlargement of lower extremities is always symmetrical, bilateral, and non-pitting, and features frequent bruising/ecchymosis because of even minor traumatic injuries, while lymphedema is more commonly asymmetric, without associated pain or bruising.

In a summary of differences between lipedema, lymphedema, and obesity, the Lymphatic Education and Research Network noted that Kaposi-Stemmer's sign is generally negative in early lipedema and positive in lymphedema. The priority when treating all types of lipedema is to restore or maintain mobility, which starts to be limited early in the disease course, with medial contact of the thighs.

The case authors stressed the importance of working with patients to identify their treatment objectives, which might include improving symptoms, losing weight/fat, reducing limb volume, increasing mobility and enhancing aesthetics, which when achieved, can improve psychological status: "Often, the patient's aesthetic desire unduly overrides the objective need to improve mobility and symptoms, and to prevent progression," they wrote.

The team noted that clinical progression -- and response to treatment -- can be monitored using objective clinical tools, such as volumetric measurements of limbs and bioimpedance and validated, culturally adapted symptom monitoring questionnaires such as the QuASiL.

Both the U.K. and the Netherlands have guidelines for clinical and surgical treatments of lipedema, all aimed at improving signs and symptoms, reducing the volume and disproportions of the affected limbs, and preventing progression, the case authors said.

When referencing findings of the 2020 international consensus conference on liposuction for lipedema, the case authors noted that "the current literature is biased in the sense that it presents liposuction as the main treatment for lipedema, and this can lead to the misapprehension that it is its only definitive treatment."

The team proposed lymphatic drainage as a strategy that patients might find more acceptable, noting that current U.S. recommendations include use of antioxidant therapy with hesperidin and diosmin, and use of quercetin, pycnogenol, flavonoids, rutosides, and butcher's broom (ruscus aculeatus) for treatment of lipedema and/or lymphedema.

A theoretical mechanism of action, the case authors said, is that a "combined sequence of natural complex antioxidants sets up a reductant cascade to match the progressive oxidative stresses of the free-radical cascade."

In the presence of commonly prevalent co-existing comorbidities such as varicose veins of the lower limbs (53% of cases) or obesity (50% of cases), "failure in the clinical treatment of lipedema may cause failure in the treatment of the associated disease," which further justifies treatment of lipedema, the authors added.

Still, they cautioned against surgical treatment during the inflammatory stage of lipedema, noting that the best time for decision-making is when the patient has reached the "best" symptomatic state. Moreover, the recent availability of liposuction with its protective effect on the lymphatic system, offers new perspectives and hope, but does not preclude non-surgical treatment, the team said.

Despite the inherent challenges, non-surgical approaches to reducing volume and disproportion are possible, the authors said. Complications of lipedema, like ulcers, lymphangitis, and erysipelas, can be a patient's main concern and those can be treated without liposuction.

Conclusion

The case authors concluded that non-surgical treatment of lipedema is feasible in selected cases, and can meet the criteria for achieving selected clinical objectives. Due to all the available therapies, an integrated multispecialty and multidisciplinary teamwork patient-centered approach is crucial.

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