Report on Lipoedema


lipedemaLipedema was described for the first time in 1940; It is a fairly common condition, and often underestimated, characterized by an abnormal accumulation of fat tissue, which sometimes blatantly distorts the appearance of the limbs or abdomen saving always the same ends of the limbs (hands and feet). Often symmetrical and bilateral, sometimes interesting the 4 limbs, it is of often mistakenly diagnosed as lymphedema, although in advanced stages the two clinical entities coexist. It is often confused with other conditions, such as obesity, when in fact in lipoedema you can find a BMI in the normal range, and from which stands out not only for a different distribution of adipose tissue, also from a poor response to diet . In this sense, the fat cells of lipoedema behave like a tissue histologically “iperbianco” with macrophage inflammatory infiltrates, increased lipogenesis, necrosis of adipocytes and abnormal accumulation of fat inside cells, but at the same time functionally as a fatty tissue that is not It decreases with reduced caloric intake (Suga H, J Araki, Aoi N, Kato H, Higashino T, Yoshimura K. Adipose tissue remodeling in lipoedema: adipocyte death and concurrent regeneration. CUTAn J Pathol 2009; 36: 1293-1298). Fat cells in humans recognize three stages of growth: a first period, around 4-5 years of age followed by a first stop replication; a second period of around 9-11 years and a third and final period of between 15 and 20-22 years. At this age, the majority of individuals, all of the fat cells (cells stable) ends its growth and it highlights the final storage in conventional arenas. A classic lipoedema emerges then the border between the last stage of adolescence and the first phase of youth, or after a pregnancy. In other cases one can speak of neolipogenesi, possible even in older age, but always dependent susceptibility and triggered by events endogenous (hormones, alcohol intake as the Madelung syndrome or other) or exogenous (eg intervention of lymphadenectomy at the root limb to the criteria of oncological, as in the case of breast cancer for the upper limb). In lipoedema pure the water component suprafascial is located essentially within the fat cells (the proof is that in prolonged standing in almost all subjects the foot remains completely dry and Stemmer sign is negative). Clinically it manifested, as well as the accumulation of adipose tissue in the lower limbs, which typically saves your feet, also with a capillary fragility, sign the fovea absent or fleeting pain and acupressure. In the differential diagnosis with lymphedema, from which it differs primarily by the absence of the sign of the fovea and the Stemmer sign, it may become difficult in the advanced stages of both diseases, when in lymphedema we can have the development of a secondary fatty tissue, while in lipoedema you can have a compromised lymphatic vessels, setting up a lipo-lymphedema (Foldi And Foldi M, eds. lipoedema. In Textbook of Lymphology Jena, Germany: Urban & Fischer, 2003; 395). The stadazione clinic has three stages on the basis of inspection pelpazione by severity: Stage 1: the surface of the skin is normal and subcutaneous adipose tissue has a soft consistency, although palpation you appreciate small nodules. Stage 2: the skin surface becomes uneven and hard with increasing nodular structure of the subcutaneous tissue. Stage 3: lobular deformation of the skin surface with the increase of the adipose tissue. Nodules are visually appreciable. (Schmeller W, Meier-Vollrath I. Modern therapie des lipödems: Kombination von und konservativen operativen maßnah men. [Modern therapy in lipedema: Combination of conservative and surgical methods]. Lymphol Forsch Prax 2004; 8: 22-26.) The causes siluppo of the lipoedema that are often hereditary and family, are still not known, although it is evident that there is a hereditary, autosomal dominant perhaps, in some family groups. (Child AH, Gordon KD, P Sharpe, Brice G, P Ostergaard, Jeffery S, Mortimer PS. 2010. lipoedema: An inherited condition. Am J Med Genet Part A 152A: 970-976). E ‘documented anamnestically a familiarity in percentages ranging from 16 to 64% of cases (Langendoen YES, Habbema L, Nijsten TE, Neumann HA. Lipoedema: from clinical presentation to therapy. A review of the literature. Br J Dermatol 2009; 161 : 980-986.). Conservative treatment of ipedema aims to reduce edema in the extracellular component, using manual lymphatic drainage and bandaging plywood, with results ranging from a reduction in limb volume up to 10%, a reduction of pain. They were recently introduced therapy with shock waves, cavitation or medical ultrasound. The latter, conducted at frequencies of around 40 kHz, has proven effective in reducing limb volume, with results equal to some surgical techniques, and with a net reduction of pain (M. Cardone, Cap F., Fiorentino A., Sainato V., A. Failla, G. Moneta, Michelini S. Effectiveness of combined conservative treatment in patients lipoedema. Proceedings XXIV Congress ISL) The surgical methods of liposuction, indicated in advanced stages of lipoedema, are not free from possible complications, and require in any case, as in the conservative treatment, repeated cycles of therapy of manual lymph drainage and compression, including the packaging of elastic garment definitive class I compression Meplat. There are also mixed forms in which coexists also a failure (usually consensual) lymphatic transport of loco-regional facilitated by the natural tendency in certain individuals (especially women) to the so-called ‘water retention’. To locate these clinical situations you can make a test: the Streeten-test. Streeten-test: the patient, in the morning, having practiced a pharmacological wash out the last 24 hours concerning acting drugs favoring diuresis or hormonal compounds, not in the premenstrual or menstrual period in women of childbearing age and not taking, in the last twelve hours of substances containing caffeine or protein, is weighed and measured at several levels of the two lower limbs in comparison. In the twenty minutes after he was invited to drink 20 ml. of water (not to diuretic action) for each kilogram of body weight (for example a subject weighing 50 Kg. must assume in 20 ‘1 liter of water). In the five hours after the patient he is asked to urinate whenever he feels the urge. He spent five hours are re-measured the circumference of the legs at the various levels of detection baseline and calculated the total quantity of urine excreted. The framework is not considered physiological (urinary retention) if the quantity of urine output is less than 60% of that taken by mouth or if the final circumferences exceed an increase of 3% compared with those initials.  

Dr. Marco Cardone