Skin Infection Assessment in Lymphedema

Primary Skin Descriptors

The skin should be described as demonstrating cellulitis with purulent discharge overlying chronic lymphedematous changes, requiring immediate assessment for necrotizing infection and initiation of MRSA-active antibiotics, as recommended by the Infectious Diseases Society of America 1, 2
Erythema extending from the wound or affected area, measured in centimeters from the margin, is a key descriptor 2
Purulent discharge indicates bacterial infection requiring culture, according to the International Working Group on the Diabetic Foot 1, 2
Local warmth, as a cardinal sign of inflammation, and edema and induration beyond baseline lymphedematous changes, are critical assessment points 2, 3
Local tenderness on palpation is also a significant finding 2

Peau d'orange appearance, dimpling of skin resembling orange peel, is a characteristic of chronic lymphedematous changes 3, 4
Woody-hard subcutaneous tissues may indicate necrotizing fasciitis, a critical distinction from superficial infection 5

In cellulitis, subcutaneous tissues remain yielding and palpable on examination, whereas in necrotizing fasciitis, tissues feel wooden-hard 5
Skin anesthesia, bullous changes, or rapid progression suggest deeper infection requiring emergent surgical consultation, as per the Infectious Diseases Society of America guidelines 5, 6

Measure erythema extension: <2 cm = mild infection; ≥2 cm = moderate infection, according to the International Working Group on the Diabetic Foot 2
Check for systemic signs: temperature >38°C or <36°C, heart rate >90 bpm, respiratory rate >20 breaths/min, indicating severe infection 2
Document presence of purulent secretions, necrosis, or friable granulation tissue 2

Chronic edema causes permanent lymphatic damage with each infectious episode, as noted by the Clinical Infectious Diseases journal 3, 5
Examine interdigital toe spaces for maceration, fissuring, scaling, or tinea pedis as bacterial entry points, as recommended by the Infectious Diseases Society of America 3, 4, 6
Look for venous eczema or other inflammatory dermatoses, and document any ulceration or trauma that disrupted the skin barrier 2, 3, 5

Describe systematically: extent of erythema, character of discharge, tissue consistency, baseline lymphedematous changes, systemic signs, and predisposing factors, as outlined by the Diabetes/Metabolism Research and Reviews journal 1, 2, 3, 4, 5