Why are these four tables often confused?
When there is thickening, swelling, a feeling of heaviness, pain or uneven skin in the legs, the same question often comes to patients' minds: "Is it lipedema, lymphedema, vascular problems, or cellulite?"
This confusion is very normal. Because some of the findings of these tables are similar to each other. In lipedema, there may be disproportionate increase in adipose tissue and pain in the legs. Fluid accumulation is at the forefront in lymphedema. In venous insufficiency, the venous system is strained, and swelling and heaviness may increase at the end of the day. Cellulite is more related to the appearance of the skin surface.
The problem is this: All of them are perceived as "image changes in the leg". However, the treatment approaches are not the same. Just telling a patient with lipedema to "lose weight" may be incomplete. If skin care and lymphatic treatment are neglected in a patient with lymphedema, the risk of infection may increase. If there is venous insufficiency, the vascular system should be evaluated. In cellulite, the disease burden and treatment goal are completely different.
What is lipedema, which is the main guide for the general definition, symptoms and diagnosis process of lipedema? Symptoms, stages and diagnostic guide are the main nexus of this article. In this article, we will separate four similar-looking paintings in simpler language.
"My leg is swelling, is this lipedema or lymphedema?"
The answer to this question cannot be given by looking at a single symptom. How the swelling started, whether it is unilateral or bilateral, whether the back of the foot is affected, whether there is pain and bruising, whether it changes during the day and whether there is skin discoloration are evaluated together.
In lipedema, the two legs are usually affected in a similar way. The increase in adipose tissue may become evident in the hips, hips, thighs, knee circumference and calf line. In the classic painting, the feet are preserved most of the time. Pain, tenderness and easy bruising are frequently described.
In lymphedema, lymph fluid accumulates in the tissue. The back of the foot and fingers may participate in the table more often. The swelling may be unilateral or more pronounced on one side. Over time, the skin may thicken, harden and develop a tendency to infection.
Therefore, it is not enough to say "there is swelling". The character of the swelling is important.
What is lipedema, what are the basic clues?
Lipedema is a chronic adipose tissue disease, especially seen in women, with painful and disproportionate adipose tissue increase. It is most commonly seen in the legs, in some patients the arms are also affected.
Findings suggestive of lipedema are: bilateral and symmetrical leg thickening, pain or tenderness to touch, easy bruising, generally protected feet, significant disproportion between the upper body and lower body, legs not thinning at the expected rate even if weight is lost.
This table isn't just about looks. Patients sometimes describe "my legs are like bruises", "it hurts when touched", "it gets very heavy towards the evening". These complaints are common in lipedema (Forner-Cordero et al., 2012 [3]; Herbst et al., 2021 [4]).
To read the symptoms of lipedema in more detail, the lipedema symptoms article will be complementary.
What is lymphedema and how is it distinguished from lipedema?
Lymphedema is a swelling that occurs when lymph fluid accumulates in the tissue. The lymphatic system is the system that carries excess fluid and proteins between tissues back into circulation. This system may be congenitally weak or may deteriorate later due to surgery, infection, trauma, radiotherapy, tumor, obesity or other reasons.
Swelling in lymphedema is often predominantly fluid accumulation. The back of the foot, fingers and ankle may be more noticeably affected. Initially, edema that leaves a pit with pressing can be seen. In the advanced period, the tissue may harden and the skin may thicken.
In lipedema, the main problem is the painful and disproportionate increase in adipose tissue. The feet are more preserved in the classical painting. Pain and easy bruising are more noticeable. But this distinction is not always immaculate. In some patients, lymphatic load may be added to lipedema. This is called lipo-lymphedema.
When lipo-lymphedema develops, the back of the foot may also swell, the edema may become more permanent, and the treatment plan changes. In this case, the lipedema approach alone is not enough; Lymphedema management should also be included in the plan.
What is venous insufficiency, what symptoms does it present?
Venous insufficiency is a condition in which the leg veins cannot carry blood up effectively enough. Veins carry blood from the legs to the heart. In this system, when the valves do not work well, blood can pool in the legs.
The most common complaints in venous insufficiency are a feeling of heaviness that increases at the end of the day, swelling that becomes evident when standing, varicose veins, fullness in the leg, itching, restlessness and sometimes night cramps. In advanced cases, brown discoloration, hardening, eczema-like appearance and wounds may develop on the skin.
Some points help in differentiating it from lipedema. In venous insufficiency, swelling may increase during the day and decrease with leg elevation. In other words, there may be relief when you lift the leg high. In lipedema, the increase in adipose tissue is permanent; Leg volume does not return to normal completely with elevation.
However, venous insufficiency and lipedema can occur together in the same patient. The presence of varicose veins alone does not mean "this is not lipedema". Therefore, the vascular system should be evaluated separately.
What is cellulite, is it the same as lipedema?
Cellulite is an orange peel-like surface irregularity that occurs under the skin due to the relationship between adipose tissue and connective tissue. It is considered more of a cosmetic appearance problem. It is common in the thigh, hip and hip area.
The reason why it is confused with lipedema is that both can change the appearance of the skin in the leg and hip area. But it is not the same thing.
Pain, easy bruising, significant symmetrical volume increase and ankle-level cuff appearance are generally not expected in cellulite. In lipedema, painful adipose tissue increase, tenderness, bruising tendency, resistance to weight loss and functional effects may be more pronounced.
A warning is needed here: The word "cellulite" in Turkish is sometimes used for the appearance of an orange peel on the skin, and sometimes it means "cellulitis", that is, subcutaneous infection, in medical terms. These two situations are not the same. In subcutaneous infection, there may be redness, increased temperature, pain and fever. Such a picture requires urgent evaluation.
Why is the retention of the feet an important point of distinction?
The condition of the feet is an important clue in the distinction between lipedema and lymphedema. In classic lipedema, the feet are usually preserved. The increase in volume in the leg may appear to be cut at the ankle level. This appearance is sometimes described as the "headline appearance".
In lymphedema, the back of the foot and fingers are more commonly affected. Narrow shoes, fullness on the back of the foot, swelling in the fingers and thickening of the skin are more noticeable in terms of lymphedema.
In venous insufficiency, edema around the ankle and lower leg may be more pronounced. Swelling may increase during the day. Standing for a long time may increase the complaint.
For this reason, the examination examines not only the thickness of the leg, but also the back of the foot, fingers, ankle passage and skin findings.
What do pain, tenderness and bruising suggest?
Pain and touch sensitivity are important findings in lipedema. The patient may say "my legs are like bruises", "it hurts when touched", "it is very sensitive when getting a massage". Easy bruising is also common in lipedema.
Pain in lymphedema is usually not as pronounced as in lipedema. There may be more of a feeling of fullness, tightness and heaviness. In the future, skin changes and infections can cause pain.
In venous insufficiency, heaviness, fullness, burning, restlessness and increased swelling at the end of the day may come to the fore rather than pain. Varicose veins, itching and skin discoloration may accompany the picture.
In cellulite, pain is not the typical main finding. Skin surface irregularity is more prominent. If there is redness, increased temperature and fever, infection should be considered, not cosmetic cellulite.
What does it mean if the swelling changes during the day?
Swelling that changes during the day may be more related to fluid balance, venous circulation and lymphatic system. Swelling that increases when standing for a long time and decreases when lifting the leg high is suggestive in terms of venous insufficiency.
Swelling in lymphedema may also increase during the day. It may decrease slightly with elevation in the early period. In advanced stages, this response may become more limited as the tissue hardens.
In lipedema, the increase in adipose tissue does not disappear during the day. However, the feeling of heaviness, fullness and edema may increase at the end of the day in the patient with lipedema. In other words, saying "it increases in the evening" does not mean venous insufficiency alone. Lipedema, venous insufficiency and lymphatic overload may coexist.
For this reason, we recommend that the patient take the measurements at the same time. The measurement made in the morning and the measurement made in the evening should not be interpreted in the same way.
What is Stemmer's sign?
Stemmer's sign is a simple examination finding used in the evaluation of lymphedema. It is considered positive if the skin is involved in the second toe root of the foot and cannot be lifted up. A positive Stemmer finding is a sign in favor of lymphedema.
Classically, Stemmer's finding is negative in lipedema. Because the feet are usually protected. However, if lymphedema is added to lipedema, that is, lipo-lymphedema has developed, the back of the foot and fingers may be affected.
This finding alone does not make a diagnosis. Examination findings, patient's history, distribution of swelling, skin findings and, if necessary, imaging are evaluated together.
Can these pictures be together in a patient?
Yes, it can. In fact, this is the most difficult situation in the clinic. A patient with lipedema may be accompanied by obesity, venous insufficiency or lymphatic overload. In this case, the symptoms are mixed with each other.
For example, the patient may experience pain and bruising in the legs due to lipedema, while he may feel more swelling in the evening due to venous insufficiency. Obesity can strain the lymphatic system. When lymphedema is added, swelling on the back of the feet can be added to the picture.
Therefore, a one-word answer is not always correct in diagnosis. Sometimes it is necessary to say to the patient, "You have lipedema, in addition to this, there are signs of venous insufficiency". Sometimes obesity and lipedema should be considered together. Sometimes the lymphatic system should be evaluated separately.
Treatment is personalized accordingly. Focusing on only one topic may leave the patient's real problem incomplete.
What symptoms require immediate evaluation?
Lipedema is usually a slow course. Sudden complaints should not be passed off as lipedema.
If there is unilateral sudden leg swelling, new-onset severe calf pain, redness and temperature increase in the leg, shortness of breath, chest pain, fainting or fever, an urgent health evaluation is required. These findings may be associated with vascular occlusion, infection, or other serious conditions.
If there is redness, increased temperature, tenderness and fever on the skin, cellulitis, that is, subcutaneous infection, can be considered medically. This condition is completely different from cosmetic cellulite.
Even if the patient has been diagnosed with lipedema before, new and sudden symptoms should be evaluated separately. It is not safe to explain these findings by saying "I already have lipedema".
What is looked for in examination and diagnosis?
In the examination, the distribution of swelling and volume increase is first checked. Bilateral or unilateral? How are the hips, thighs, knee circumference, calves, ankles and back of the feet affected? Are the arms stiff?
Then the skin and tissue structure are evaluated. Is there an orange peel appearance on the skin, nodules, edema that leaves a pit with pressing, discoloration or hardening of the skin?
Pain and tenderness are also questioned. Easy bruising, feeling of heaviness at the end of the day, increase in hot weather, relationship with menstrual period and regional response to weight loss are evaluated.
Venous Doppler ultrasound may be required for the vascular system. Lymphatic evaluation can be performed in case of suspicion of lymphedema. However, the diagnosis of lipedema is often made with a good history and careful physical examination. A single blood test or a single imaging method does not confirm lipedema (Peled and Kappos, 2016 [7]; Herbst et al., 2021 [4]).
Why is the treatment approach different?
Although these four pictures are similar, the treatment goals are different.
The goal of lipedema is to reduce pain, tenderness, edema, limitation of movement and metabolic load. Nutrition, low-impact exercise, manual lymph drainage, compression, weight management, and surgical options in selected patients are considered together.
Controlling lymphatic fluid accumulation is more important in lymphedema. Compression, skin care, manual lymph drainage, exercise and reducing the risk of infection are more prominent.
In venous insufficiency, the venous system should be evaluated. Compression, movement, leg elevation, weight management and vascular treatments may be considered in appropriate patients.
In cellulite, the goal is often to improve cosmetic appearance and skin texture. If there is medical cellulite, that is, infection, the treatment changes completely; antibiotics and urgent evaluation may be required.
That's why accurate diagnosis is important. Because the patient cannot reach the right treatment without the right nomenclature.
Frequently asked questions
Question: Are lipedema and lymphedema the same thing?
Answer: No. Lipedema progresses with painful and disproportionate increase in adipose tissue. In lymphedema, the accumulation of lymph fluid in the tissue is at the forefront. In lymphedema, the back of the foot and fingers may be affected more frequently.
Q: Why are the feet usually preserved in lipedema?
Answer: In classical lipedema, the increase in adipose tissue mostly extends to the ankle level and the feet are relatively preserved. If there is significant swelling on the back of the foot or fullness in the fingers, evaluation is required for lymphedema or lipo-lymphedema.
Question: Can venous insufficiency be associated with lipedema?
Answer: Yes. A patient with lipedema may also have venous insufficiency. If there is varicose veins, increased swelling at the end of the day, heaviness in the leg, itching and skin discoloration, the vascular system should be evaluated separately.
Question: Are cellulite and lipedema the same thing?
Cellulite usually describes the orange peel appearance on the surface of the skin. In lipedema, pain, tenderness, easy bruising, symmetrical adipose tissue increase and functional effects can be seen.
Question: What does it mean if the Stemmer finding is positive?
Answer: Stemmer's finding is that the skin on the root of the second toe of the foot cannot be held and lifted. A positive finding is in favor of lymphedema. However, the diagnosis is not made by this finding alone.
Question: Can unilateral sudden leg swelling be lipedema?
Answer: Lipedema is a picture that usually develops slowly and is bilateral. If there is unilateral sudden swelling, redness, increased temperature, severe pain, shortness of breath or chest pain, urgent evaluation is required.