Review

Lymphedema vs lipedema: Similar but different

Laura Daniela Lomeli, BA, Vinni Makin, MD, John R. Bartholomew, MD and Bartolome Burguera, MD, PhD
Cleveland Clinic Journal of Medicine July 2024, 91 (7) 425-436; DOI: https://doi.org/10.3949/ccjm.91a.23084

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    The patient had bilateral leg swelling with sparing of the feet. Note the ankle cutoff, or cuff sign. Her thighs also had a mattress-like appearance with numerous painful, palpable nodules.

  • Figure 2
    Figure 2

    Lymphedema. Note the exaggerated skin creases at the base of the toes of the left foot and pitting edema in the anterior mid-thigh. There is also a dorsal hump on the top of the left foot.

  • Figure 3
    Figure 3

    Algorithm for lipedema management.

    aNot all of the clinical criteria for the diagnosis of lipedema must be present (see “Diagnostic evaluation” in the “Is This Lipedema?” section of this article), but a combination of the criteria is often present.

    Adapted from reference 6.

Tables

  • TABLE 1

    Lipedema, lymphedema, and obesity compared

    LymphedemaLipedemaObesity
    Sex affectedBoth men and womenAlmost exclusively womenBoth men and women
    Family historyPresent in primary lymphedema, absent in secondaryPresentPresent or absent
    EdemaNonpitting (early) or pitting, unilateral or bilateralNonpitting, bilateralBilateral
    Swollen feetPresentAbsent unless patient has lipolymphedema or phlebolymphedemaPresent
    Increased fatty tissueAbsentPresent and usually nodularPresent
    Abnormal distribution of adipose tissuePossiblePresent in arms, abdomen, buttocks, and legsPossible
    Tenderness and painAbsentPresentAbsent
    Tendency to develop hematomasAbsentPresentAbsent
    Cuff signaNegativePositive
    Embedded Image    		Positive
    Stemmer signbPositive
    Embedded Image    		NegativeNegative
    Weight-loss treatmentRecommended to reduce lymphatic harmMay not reduce size of affected region but is recommended to minimize complications and if metabolic syndrome is presentRecommended

    • ↵a Tissue enlargement stops abruptly at the ankle or wrists (arms affected in up to 80% of patients).

    • ↵b Inability to pinch a fold of skin at the base of the second toe compared with the opposite foot.

    • Based on information from references 1–6.

  • TABLE 2

    Primary lymphedema: Genetic basis and key features

    Gene affectedKey features
    Congenital
    Milroy lymphedema (hereditary lymphedema type 1A)FTL4 (VEGFR3)Nonsyndromic
    Hereditary lymphedema type 1BUnknownNonsyndromic
    Milroy-like lymphedema (hereditary lymphedema type 1D)VEGFCNonsyndromic
    Congenital lymphedema syndromesVariesSpecific to syndrome
    Lymphedema praecox
    Meige disease (hereditary lymphedema type 2)UnknownNonsyndromic
    Lymphedema distichiasis syndromeFOXC2Ptosis, secondary eyelash formation, corneal abrasions
    Primary lymphedema with myelodysplasia (Emberger syndrome)GATA2Myelodysplasia, congenital deafness may be present
    Hereditary lymphedema type 1CGJC2Myelodysplasia, congenital deafness may be present
    Hypotrichosis-lymphedema-telangiectasiaSOX18Vascular malformations including aortic dilation and cutaneous telangiectasias, hypotrichosis
    Yellow nail syndromeUnknownTriad of yellow-green nails, respiratory symptoms, and lymphedema
    Lymphedema tardaFOXC2Unilateral or bilateral lymphedema presenting after age 35

    • Adapted from reference 9.

  • TABLE 3

    Management of lymphedema diagnosed clinically or by lymphoscintigraphy

    Refer to vascular medicine or surgery, plastic surgery, or both
    Start conservative therapy

    • • Refer to physical therapy and consider manual lymph drainage

    • • Continuous compression garment use (circular vs flat knits)

    Assess response to therapy at 6 months

    • • If symptoms are improved, continue conservative therapy, including compression garment use with annual prescription depending on patient compliance

    • • If symptoms do not change or if they worsen, consider referral to surgery for debulking or excisional or suction-assisted lipectomy in healthy patients at low surgical risk

    • Adapted from reference 26.

  • TABLE 4

    Lipedema: Clinical stages and compression recommendations

    StageCharacteristicsCompression recommendations
    1Smooth skin, homogenous increase in subcutaneous tissue, cool skin in certain areas
    Subdermal pebble-like feel due to underlying loose connective tissue fibrosis
    Small nodules
    Edema reverses with elevation
    Circadian rhythmicity    		Micromassage compression garment 10–20 mm Hg as needed
    2Irregular or uneven skin surface (skin dimpling)
    Palpable nodules (may be walnut size)
    Nodular change of subcutaneous tissue
    Tissue begins to hang off the arm, wrist cuff sign
    Reversible or irreversible edema
    Moderate to severe fibrosis
    Circadian rhythmicity    		Micromassage compression garment 20–40 mm Hg if pain, swelling, or heaviness is present
    3Tender subcutaneous nodules
    Pronounced increase in circumference with loose skin and tissue
    Bulging protrusion of fat mainly at inner and outer thighs and knees
    Marked sclerosis and fibrosis
    Often concomitant lymphedema with a positive Stemmer sign (lipolymphedema)    		Micromassage compression garment 20–40 mm Hg as tolerated if pain, swelling, or heaviness is present
    May have to layer different garments

    • Based on information from references 4,5,43.

Back to top

In this issue

Print
Download PDF
Article Alerts
Email Article
Citation Tools

Jump to section

Subjects