Pattern Differentiation and Treatment of Lower-Limb Lymphedema (Obstruction of Lymphatic Return)

Lower-limb lymphedema is a chronic progressive disease in which impaired lymphatic return causes lymph to accumulate continuously in the subcutaneous tissue, even leading to fibrous tissue proliferation. Modern lymphedema is divided into primary and secondary types. The cause of primary lymphatic obstruction is often unclear; secondary lymphedema is mostly due to surgical removal of lymphatic tissue and is a common postoperative sequela in many tumor patients. In addition, childbirth and trauma can also cause secondary lower-limb lymphedema. Rest or leg elevation can reduce symptoms, and tight garments may help, but neither cures the condition.

Because of its symptoms, TCM calls lower-limb lymphedema "big-foot wind" or "elephant leg." The Qizhai Yian records: "Among farmers in watery regions, many have swollen feet, commonly called big-foot wind." "This is caused by injury to the collaterals with congealing stasis, obstruction of qi and blood, and invasion of mixed wind, damp and evil heat that cannot exit." The lymphedema recorded in the Qizhai Yian was mostly caused by filariasis. In areas with many paddy fields, many farmers still suffer from this disease.

In the early stage, the patient's lower-limb skin is tight and leaves a pit on pressure; later the skin becomes thick and rough, and the limb enlarges and hardens like elephant hide. Traditional TCM holds that this disease is mostly caused by cold-damp evil invading and lingering, transforming into heat over time and pouring downward to the lower limbs, blocking the meridians; or by spleen deficiency with water retention and internal phlegm-dampness, obstructing qi movement, blocking the meridians and congealing qi and blood. It is therefore treated according to patterns such as yang deficiency with water flooding, spleen deficiency with damp obstruction, damp-heat pouring downward, or intermingled phlegm and stasis.

Lower-limb lymphedema should be differentiated from lower-limb edema due to ascites or pelvic effusion, because the symptoms are sometimes similar; but the former has no ascites or pelvic effusion and thus lacks the abdominal distension, abdominal pain and difficult urination and defecation that often accompany them. Lymphatic obstruction after cancer surgery is usually difficult to treat, but medication can still relieve symptoms and improve quality of life.

In addition, kidney disease and heart failure also cause lower-limb edema with symptoms similar to lymphedema. But when kidney disease causes lower-limb edema, blood protein falls markedly; heart-failure patients have shortness of breath, fatigue and palpitations, and ECG abnormalities appear. Both are therefore easily diagnosed.

When treating lower-limb lymphedema, clinicians should carefully exclude these serious conditions so as not to delay treatment. Once the diagnosis is accurate, treat according to the patient's clinical presentation and the different patterns.

1. Yang deficiency with water flooding pattern

Such patients often have a dark, lusterless complexion, a water-slippery tongue, heavy limbs and difficult urination. Treatment should focus on Zhen Wu Tang (True Warrior Decoction), or Jisheng Shenqi Wan (Life-Saving Kidney-Qi Pill) may be used.

Zhen Wu Tang formula: Fuzi 15 g, Baizhu 12 g, Fuling 9 g, Baishao 9 g (use Chishao for blood stasis), Renshen 6 g.

Jisheng Shenqi Wan is sold as a prepared medicine under that name, available in offline or online pharmacies. In addition, the Jinkui Shenqi Wan containing Cheqianzi (Plantaginis Semen) and Niuxi (Cyathulae Radix) made by Tong Ren Tang and other patent-medicine factories is also made to the Jisheng Shenqi Wan formula.

2. Spleen deficiency with damp obstruction pattern

Such patients have obvious lower-limb edema, swelling and pain, with pits that are slow to rise on pressure; a pale, enlarged tongue often with teeth marks; a white greasy coating; and a soft, weak pulse. Treatment should mainly fortify the spleen and drain dampness, supplemented by activating blood and unblocking collaterals. Compose mainly with Guipi Tang combined with Shenling Baizhu San (Ginseng-Poria Atractylodes Powder); or use the patent medicines Guipi Wan and Shenling Baizhu granules together in place of a decoction.

Reference formula: Sheng Huangqi 30 g, Renshen 6 g (or Dangshen 15-30 g), Baizhu 10 g, Fuling 10 g, Muxiang 10 g, Houpo 10 g, Danggui 10 g, Longyanrou (Longan Arillus) 6 g, Fuling 12 g, Suanzaoren (Ziziphi Spinosae Semen) 10 g, Baibiandou (Lablab Semen album) 10 g, Lianzirou (Nelumbinis Semen) 15 g, Yiyiren 30 g. For diarrhea and loose stools, add Baitouweng 15 g and Qinpi (Fraxini Cortex) 6 g; for marked lower-limb edema with varicose veins, add Niuxi 10 g, Dilong 15 g and Mugua (Chaenomelis Fructus) 30 g as appropriate.

3. Damp-heat pouring downward pattern

Such patients' lower-limb skin is often accompanied by redness, swelling, heat and pain, and even chills, fever and joint soreness; the tongue is red with a yellow greasy coating and the pulse is slippery. Consider treating with modified Simiao Wan (Four-Wonder Pill) combined with Bixie Shenshi Tang (Dioscoreae Septemlobae Damp-Percolating Decoction).

Reference formula: Cangzhu 10 g, Huangbai 10 g, Huainiuxi (Cyathulae Radix) 15 g, Yiyiren 30 g, Bixie (Dioscoreae Septemlobae Rhizoma) 15 g, Mudanpi 10 g, Cheqiancao (Plantaginis Herba) 10 g, Yimucao (Leonuri Herba) 15 g, Zelan (Lycopi Herba) 10 g, Tongcao (Tetrapanacis Medulla) 6 g, Pugongying 15 g, Zihuadiding 10 g.

4. Intermingled phlegm and stasis pattern

The intermingled phlegm and stasis pattern usually appears when edema has persisted for a long time, causing the affected limb to swell, enlarge and harden, with rough, elephant-like skin; some patients also have chronic ulcers that do not heal. Strictly speaking, such patients have intermingled phlegm, stasis and heat, with deficiency and excess mixed, so treatment should combine heat-clearing and toxin-resolving, blood-activating and stasis-resolving, qi-boosting and blood-nourishing, and damp-draining and phlegm-resolving principles.

Reference formula: Sheng Huangqi 50-120 g, Baiji 10-30 g, Jinyinhua 60-120 g, Taoren 10 g, Honghua 6 g, Danggui 10 g, Chishao 10 g, Chuanxiong 6 g, Danshen 10 g, Dangshen 10-30 g, Huangjing 10-30 g, Dilong 6-15 g, Tubiechong 10-15 g, Baizhu 10 g, Fuling 10 g, Zhi Gancao 6 g.

Lymphedema usually requires a long course; long-term decoction use is impractical. If the above formulas are effective, they may be ground into powder, mixed with excipients and made into pills for continued use.