18 Steps to Prevention

By Saskia R.J. Thiadens, RN

National Lymphedema Network

It was in 1990 when I wrote the 18 Steps to Prevention for upper and lower limbs. Since that time, these guidelines have been widely used in doctor's offices, breast centers, hospitals, support groups, and publications around the country and the world. Without evidenced-based data, it has been and continues to be difficult to support and justify these Steps. The Medical Advisory committee (MAC) of the NLN came to the realization that this document needed to be strengthened and updated, which is a sign of progress in the world of lymphology. Because we do not know all the complex and interactive factors placing an individual at risk for lymphedema and, therefore, cannot totally prevent its occurrence based on our current level of knowledge, we focus on reducing risk of occurrence based on our best knowledge. Over the last 15 years, we have developed tremendous insight of the lymphatic system and I am pleased to deliver this new NLN Position Paper on Risk Reduction guidelines. Please update your educational materials and protocols immediately and alert your colleagues, as well. Thank you.
I. Skin Care - Avoid trauma / injury to reduce infection risk

  • Keep extremity clean and dry
  • Apply moisturizer daily to prevent chapping/chafing of skin2
  • Attention to nail care; do not cut cuticles
  • Protect exposed skin with sunscreen and insect repellent
  • Use care with razors to avoid nicks and skin irritation
  • If possible, avoid punctures such as injections and blood draws
  • Wear gloves while doing activities that may cause skin injury (i.e., washing dishes, gardening, working with tools, using chemicals such as detergent)\
  • If scratches/punctures to skin occur, wash with soap and water, apply antibiotics,and observe for signs of infection (i.e. redness)
  • If a rash, itching, redness, pain, increased skin temperature, fever or flu-like symptoms occur, contact your physician immediately for early treatment of
    possible infection

II. Activity / Lifestyle

  • Gradually build up the duration and intensity of any activity or exercise
  • Take frequent rest periods during activity to allow for limb recovery
  • Monitor the extremity during and after activity for any change in size, shape,
  • Tissue, texture, soreness, heaviness or firmness
  • Maintain optimal weight

III. Avoid Limb Constriction

  • If possible, avoid having blood pressure taken on the at-risk extremity
  • Wear loose fitting jewelry and clothing

IV. Compression Garments

  • Should be well-fitting
  • Support the at-risk limb with a compression garment for strenuous activity (i.e. weight lifting, prolonged standing, running) except in patients with open wounds
    or with poor circulation in the at-risk limb
  • Consider wearing a well-fitting compression garment for air travel
  • NLN Position Paper: Lymphedema Risk Reduction Practices

V. Extremes of Temperature

  • Avoid exposure to extreme cold, which can be associated with rebound swelling, or chapping of skin
  • Avoid prolonged (greater than 15 minutes) exposure to heat, particularly hot tubs and saunas
  • Avoid placing limb in water temperatures above 102°Fahrenheit (38.9°Celsius)

VI. Additional Practices Specific to Lower Extremity Lymphedema

  • Avoid prolonged standing, sitting or crossing legs
  • Wear proper, well-fitting footwear and hosiery
  • Support the at-risk limb with a compression garment for strenuous activity except in patients with open wounds or with poor circulation in the at-risk limb

NOTE: Given that there is little evidence-based literature regarding many of these practices, the majority of the recommendations must at this time be based on the knowledge of pathophysiology and decades of clinical experience by experts in the field.

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