Lipodema: Therapy, Symptoms, Causes

Brief overview

• Treatment: Compression therapy, manual lymphatic drainage, exercise, weight control, surgical procedures such as liposuction (liposuction)
• Symptoms: Symmetrical increase in fatty tissue on the legs (and/or arms), pressure and tension pain, tendency to bruising, disproportionate, typically hands and feet are not affected
• Causes and risk factors: Not fully understood, probably genetic factors, hormonal influences, particularly oestrogen
• Prevention: No general prevention possible, weight control, exercise and early therapy to prevent progression of the disease
• Disease progression and prognosis: No cure possible, symptom relief through appropriate treatment methods

What is lipoedema?

Lipoedema is characterized by an increase in subcutaneous fatty tissue in certain areas of the body. This particularly affects the buttocks, hips and thighs. In addition to the increased subcutaneous fat, water is deposited in the tissue (edema). Lipoedema is only considered a disease when the changes cause symptoms.

How does the operation proceed and what other treatments are available?

However, the course of the disease can be mitigated – through conservative and/or surgical treatment methods.

An important aspect of lipoedema treatment is to reduce factors that promote the condition.

These include above all

• being overweight
• Water retention in the tissue (oedema)
• Psychological stress

Physiotherapy

The therapy includes manual lymphatic drainage in the form of scooping, rotating and pumping movements. The therapist first performs these on the trunk away from the lipoedema in order to create suction. Lymphatic drainage is then performed in the area of the lipoedema itself.

Manual lymphatic drainage is initially performed daily for one hour over a period of three to four weeks.

Compression treatment

Other physiotherapeutic procedures are also sometimes helpful in the treatment of lipoedema. These include shock wave therapy, for example. It improves blood circulation in the tissue. The so-called intermittent pneumatic compression exerts alternating low and high pressure on the affected area by machine.

Inpatient physiotherapy is sometimes recommended for patients with severe lipoedema.

Sport is an important part of therapy

Although there is no specific therapy to treat lipoedema itself, sport and exercise are important pillars in the treatment of lipoedema. Although this does not reduce the number of fat cells, it still makes sense: physical activity ensures that you remain mobile and agile.

Exercise also helps to reduce excess weight and maintain a healthy body weight.

What role does diet play in lipoedema?

There is no specific lipoedema diet that helps against the symmetrical increase in fatty tissue on the legs and/or arms. However, weight gain or obesity increase the risk of lipoedema worsening. A balanced diet is therefore advisable in order to achieve or maintain a healthy body weight.

Other conservative measures

Lipoedema treatment also includes skin care. It prevents inflammation and infection in the affected skin area. It is therefore important to apply cream carefully to the skin so that it does not become dry and cracked. It is advisable to treat small injuries immediately so that they do not become inflamed or infected.

Lipoedema surgery: liposuction

Lipoedema can be treated surgically using liposuction. Excessive subcutaneous fatty tissue is permanently removed. The procedure is performed, for example, if the symptoms persist or even increase despite conservative lipoedema therapy.

Liposuction is also indicated if the subcutaneous fatty tissue continues to increase despite consistent conservative treatment.

Liposuction improves the symptoms of most patients over many years. In particular, pain and the tendency to bruise can be reduced by the procedure, and the circumference of the affected extremities is also reduced.

Conservative measures (e.g. compression) are often no longer necessary after liposuction or are only necessary to a lesser extent.

Liposuction procedure

It is advisable to have liposuction for lipoedema performed only at specialized centers – either on an outpatient or inpatient basis.

Liposuction is roughly carried out in two steps:

• The doctor uses a cannula to introduce a large amount of a special irrigation fluid into the lipoedema tissue. This so-called tumescent solution contains a local anesthetic, common salt and adrenaline, among other things.

This technique is also called “wet” liposuction. It is sometimes supported by a water jet or vibration:

• Water-jet assisted liposuction (WAL): After administering the tumescent solution, the fat is loosened with a fan-shaped water jet and suctioned out.
• Vibration liposuction: The suction cannula is made to vibrate. As fat cells are more inert than blood vessels and nerve cells, they are loosened and suctioned out.

A maximum of five liters can be removed in one session. In severe cases, several sessions are therefore usually necessary to significantly reduce the lipoedema.

As with any surgical procedure, (severe) side effects are possible with liposuction. Among other things, there is a risk of damaging the lymphatic system. Secondary lymphoedema then develops as a result.

What are the symptoms of lipoedema?

Lipoedema is characterized by an increase in fatty tissue on the extremities. The legs are usually affected. Less frequently, lipoedema develops on the arms (especially the upper arms). Occasionally, both arms and legs are affected. Very rarely, lipoedema develops in other parts of the body (abdomen, etc.).

Lipoedema of the legs sometimes also affects the buttocks evenly. However, the feet are left out. The hands are also left out in the case of lipoedema on the arms. A so-called “fat collar” is sometimes noticeable at the transition between the lipoedema and the hands or feet.

Lipoedema occurs more frequently in conjunction with general obesity, but does not necessarily have to. It is also often observed in very slim women. Lipoedema therefore has nothing to do with body constitution!

Inflammations and infections form more easily in the skin folds caused by the proliferation of fatty tissue.

Small lumps can often be felt in the subcutaneous fatty tissue of the affected extremities, which sometimes become larger as the condition progresses. In later stages, so-called dewlaps (fat lobes) form.

Pain and bruising

Lipoedema pain is sometimes so severe, especially in the later stages of the disease, that those affected move less and are restricted in their everyday life.

Lipoedema symptoms include an increased tendency to bruise: even minor injuries cause a “bruise”. However, there is no coagulation disorder throughout the body. The vessels in the affected tissue are presumably more vulnerable. As a result, bruises form more quickly than in other people.

Lipoedema is a progressive disease. This means that the symptoms of lipoedema increase if left untreated: for example, first-degree, mild lipoedema usually develops into advanced lipoedema with large increases in fatty tissue.

This can be very emotionally stressful for those affected. Many patients feel increasingly uncomfortable in and with their body. Self-esteem suffers and sometimes anxiety and depression develop.

Lipedema or obesity? Differences to other diseases

Lipoedema symptoms are often confused with the signs of other diseases. For example, being very overweight (obesity) causes similar symptoms. The same applies to lymphoedema and lipohypertrophy.

Some people ask themselves how cellulite and lipoedema can be distinguished from each other. Although cellulite (“orange peel skin”) often appears as a wave-like skin condition on women’s buttocks and thighs, it is not a disease.

The following table lists the most important differences between lipoedema, lymphoedema, lipohypertrophy and obesity:

Lipoedema	Lymphedema	Lipohypertrophy	obesity
Otherwise, the affected person is usually slim. This makes the body appear clearly disproportionate.	Asymmetrical (one-sided) increase in fatty tissue. If a leg or arm is affected, then usually also the foot/hand. Body appears slightly disproportionate.	Symmetrical increase in fatty tissue on both legs (and buttocks). Body appears clearly disproportionate.	Excess fat pads more or less everywhere on the body. Normal or slightly uneven body proportions.
	With water retention in the tissue (edema).	No water retention in the tissue.	Water retention in the tissue (edema) possible.
Pressure pain.	No pressure pain.	No pressure pain.	No pressure pain.
Significant tendency to bruising.	No tendency to bruise.	Tendency to bruising possible.	No tendency to bruise.

The individual clinical pictures sometimes occur in combination, for example if those affected are obese in addition to having lipoedema.

How can lipoedema be recognized?

But which doctor is the right person to consult if you have lipoedema? If lipoedema is suspected, it is advisable to consult a specialist. These include dermatologists as well as vein and lymph specialists (phlebologists and lymphologists).

Doctor-patient consultation

First of all, the doctor will talk to you in detail to take your medical history (anamnesis). Possible questions the doctor may ask are

• Do you tend to bruise in the affected body area?
• How long have you had these complaints? Have they changed over time?
• Are you taking hormone supplements (men and women) or are you in a phase of hormonal change (women, e.g. puberty, pregnancy, menopause)?
• What have you done so far to combat the strong increase in fatty tissue (weight loss attempts, sport, etc.)?
• Are similar cases known in your family?

Physical examination

Together with the findings from the consultation, a targeted physical examination is usually sufficient for the doctor to make a diagnosis of lipoedema. Even the symmetrical increase in fatty tissue on the extremities with an otherwise slim torso provides a clear indication.

The so-called Stemmer’s sign is used to differentiate between lipoedema and lymphoedema, for example on the leg. It is positive if no skin fold can be lifted from the forefoot. This is not possible with lymphoedema. With lipoedema, however, it is possible: the skin on the foot (on the hand) can be lifted slightly.

But be careful: as there are also mixed forms of lipoedema and lymphoedema, a negative Stemmer’s sign does not rule out lipoedema!

The doctor carefully inspects the affected area and looks for skin changes. For example, he checks whether the skin is taut and whether lumps can be felt in the subcutaneous tissue. The affected area is usually very painful and vulnerable. In addition, inflammation and infections sometimes develop in skin folds with lipoedema.

It is also useful to calculate the ratio of waist circumference to hip circumference or to body height. This makes it easier to recognize whether the fat distribution is disproportionate.

Lipoedema classification

Lipoedema can be classified according to various criteria:

Depending on the location of the lipoedema, doctors differentiate between the thigh type, whole leg type, lower leg type, upper arm type, whole arm type and lower arm type. Many patients also have a mixed pattern (such as thigh and upper arm type).

• Lipedema stage 1 (initial stage): Smooth skin surface, evenly thickened and homogeneous subcutis
• Lipoedema stage 2: Uneven, predominantly undulating skin surface; nodular structures in the subcutis
• Lipoedema stage 3: Pronounced increase in circumference in the affected body area with overhanging parts of the body (dewlap)

Imaging and functional examinations

Imaging examinations are not necessary for the diagnosis of lipoedema. However, experienced physicians sometimes examine the affected region with ultrasound to assess the size of the lipoedema and the condition of the blood vessels.

Magnetic resonance imaging (MRI) or computer tomography (CT) is only performed on lipoedema patients in individual cases. These procedures are usually used to clarify other diseases.

Alternative diagnoses

As lipoedema sometimes resembles other diseases, it is important to differentiate between other causes.

These differential diagnoses include

• Severe overweight (obesity)
• lymphoedema
• Lipohypertrophy
• Lipoma (circumscribed, encapsulated and harmless fatty tumor)
• Other forms of edema such as myxedema (edema-like swelling of the subcutaneous tissue due to thyroid disease)
• Dercum’s disease (obesity dolorosa)
• Madelung’s syndrome (increase in fatty tissue in the neck, around the shoulder region or in the pelvic area)
• Fibromyalgia (chronic rheumatic disease with severe muscle pain)

What are the causes of lipoedema?

The exact causes of lipoedema are not known. However, experts have a few assumptions. For example, the hormonal system and a genetic predisposition appear to play a decisive role in the development of lipoedema.

At the same time, according to current knowledge, there is no evidence that a poor diet, too little exercise or other “bad behavior” causes lipedema.

Hormones

The hormone oestrogen in particular is thought to play an important role in the development of lipoedema. Fat cells react to oestrogen through special docking sites (receptors) on their surface.

In the few men with lipoedema, a hormonal disorder can always be detected. This also suggests that hormones are involved in the development of lipoedema.

Causes of hormonal changes in men with lipoedema are, for example

• A lack of testosterone or growth hormone
• Hormone therapy, e.g. as part of treatment for prostate cancer

The hormonal changes and disorders lead to imbalances in the body’s internal weight control, the nerves in the fatty tissue and to inflammatory processes.

Genetic predisposition – is lipoedema hereditary?

Vascular damage

In addition to the fatty tissue disorder, lipoedema is thought to be caused by an inflammatory dysfunction of the vessels in the patient’s subcutaneous tissue. The vessels in the affected area are said to have “leaks” that promote the transfer of fluid into the tissue. This also makes them more susceptible to bruising and contributes to the pain.

Can lipoedema be prevented?

However, there are measures that can help to prevent the progression or worsening of lipoedema. These include a balanced diet, a healthy body weight and regular exercise. Early treatment is also important to prevent the progression of lipoedema.

Is there a cure for lipoedema?

If lipoedema has been diagnosed, treatment is essential. This can prevent it from progressing further and restricting the quality of life of those affected. According to current knowledge, it is not possible to cure lipoedema. However, modern treatment methods can significantly alleviate the symptoms.