Brawny Edema

What is brawny edema?

Edema is the accumulation of fluid, either in cells or in interstitial space. Normally there is some fluid in the interstitial space, approximately 20% of the body weight. Some conditions can cause this amount to increase, resulting in edema. There are two types of edema- pitting and non-pitting. If pressing on the affected skin leaves a mark, it means that it is pitting edema. In case there is no mark- it is non-pitting edema, otherwise known as brawny edema.

Brawny edema is present in later stage of non-pitting edema. The chronic condition causes skin to become thick, brown – colored, atrophic and even necrotic [1,2].

Pathophysiology and Types

Edema can be a symptom of many different conditions. It results from abnormally increased movement of fluid from blood vessels into the interstitial space. Another mechanism is that the fluid from interstitial space moves to the blood vessels too slowly, resulting in edema.

There are two main types of brawny edema- lymphedema and myxedema. In case of lymphedema the lymphatic vessels are blocked. The excess fluid in the tissue can’t move into the circulation, therefore pressure doesn’t leave a pit in the skin. In case of myxedema, there are also other tissue under the skin, not only the fluid, which causes edema.

Due to chronic stasis of fluid, the blood supply becomes decreased in the affected areas and the tissue get affected by the lack of oxygen [3]. Read more about ischemia in Thoracic outlet syndrome.

Brawny Edema

Causes

The underlying pathology in brawny edema is either lymphedema or myxedema. Lymphedema is caused by removal, obstruction or alteration of lymph nodes. This can happen in case of:

  • Tumor
  • Infection (Filariasis)
  • Surgery
  • Mastectomy
  • Congenital defects (congenital lymphedema -Milroy’s disease)
  • Trauma
  • Radiotherapy.

Myxedema is caused by Grave’s disease. Grave’s disease causes interstitial dermopathy, which leads to fluid build-up in the interstitial space.

Non-pitting edema can also be caused by lipedema- the fluid buildup in the tissue is accompanied with fatty tissue. This type of edema starts around puberty. The exact cause of it is not known [4].

Symptoms

The symptoms often depend on the underlying cause. Usually edema affects lower extremities. After mastectomy, edema usually affects the arm on the side of the surgery- the edema is present where the regional lymph nodes have been removed or damaged.

The skin is usually hard and feels thick. When pressing a finger in the skin, there is no pitting, but swelling can still be observed.

Chronic edema leads to decreased blood flow. The brown color of the skin, which is characteristic to brawny edema is due to hemosiderin from the lysed red blood cells. Chronic ischemia leads to skin atrophy, dryness of skin, scaling and itching, ulceration and necrosis [5].

Diagnosis

Brawny edema can usually be diagnosed after clinical examination. The skin is thick and edema is non-pitting. To determine the course of treatment it is important to find the underlying cause of the edema and exclude other possible conditions.

Blood analyzes should include:

  • Complete blood count
  • Liver enzymes
  • Kidney function markers
  • Infection markers and specific antigens/antibodies (for example, to exclude filariasis)
  • Genetic testing for congenital defects
  • Thyroid hormone levels for diagnosing Grave’s disease. Endocrine disorders can also manifest as muscle-skeletal system disorders.

Imaging studies are usually used to exclude acute situations, for example, ultrasound is used to exclude deep venous thrombosis. Also, ultrasound can be used to examine thyroid gland. To find out the cause of lymph node blockage, magnetic resonance imaging should be used.

T1 weighted magnetic resonance lymphangiography can show the exact localization of blockage. By knowing this, it can be easier to decide the course of treatment. CT and MRI scanning can also help to find tumor that has invaded the lymph nodes. X-ray mammogram should be performed to exclude breast cancer [6].

Treatment

Treatment of brawny edema is usually very challenging, and it also depends on the underlying cause. Treatment includes usage of medications, physical therapy, surgery and different remedies.

Lymphedema

There is no cure for lymphedema, but the treatment options focus on decreasing symptoms and discomfort. These methods include:

  • Elastic stockings and sleeves
  • Bandages
  • Pneumatic compression devices- can prevent scarring, but can’t be used by people with infection and congestive heart failure
  • Manual compression- massages, lymph drainage
  • Exercises to stimulate lymph flow.

In some cases surgery is used to remove excess fluid, or in severe cases, tissue. Still, there is no effective method to cure lymphedema [7].

Brawny Edema

Lipedema

Lipedema doesn’t have a treatment, but it can be managed by using several methods. Weight loss is not effective in treating edema, but it can help to prevent further progression of edema and prevent infection. Other methods that can be used to manage lipedema are:

  • Manual lymphatic drainage
  • Compressions with stockings, wraps or pneumatic compression
  • Exercise- removes fluid buildup and increases mobility
  • Liposuction- removal of the lipedema fat [8]

Grave’s disease

If the edema is caused by Grave’s disease, the treatment primarily should focus on the underlying condition. Usually radioactive iodine therapy is used, as well as surgical removal of a part of thyroid gland. For brawny edema, use of hydrocortisone cream can be effective. Hydrocortisone cream is widely used in many skin conditions. Also, wraps, compression stockings can be used [9].

Other conditions

When brawny edema is caused by a tumor, surgical removal of the tumor should be considered. Tumor surgery, stopping of radiotherapy can be beneficial to treating brawny edema, but the risks have to be weighed against the benefits [1].

Pictures

brawny Edema 2 brawny edema lower-extremities-erythematous-brawny-edema

References

  1. General information about edema: http://www.medicinenet.com/edema/article.htm
  2. What is brawny edema: http://medical-dictionary.thefreedictionary.com/brawny+edema
  3. Pathophysiology: http://yanyu.ca/mednotes/Course%204/Edema.pdf
  4. Causes: http://www.aafp.org/afp/2013/0715/p102.html
  5. Symptoms: http://patient.info/doctor/peripheral-oedema
  6. Diagnosis: http://www.medicinenet.com/lymphedema/page3.htm#how_is_lymphedema_diagnosed
  7. Lymphedema treatment: http://www.medicinenet.com/lymphedema/page4.htm
  8. Lipedema treatment: http://www.webmd.com/women/guide/lipedema-symptoms-treatment-causes
  9. Grave’s disease treatment: http://www.mayoclinic.org/diseases-conditions/graves-disease/basics/lifestyle-home-remedies/con-20025811

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