Exploring the Updated S2k Guidelines for Lipedema Management

Since the S1 guideline on lipedema was drawn up in December 1998, the view of the disease has changed. For this reason, the aim of revising the guideline from the outset was to write an S2k guideline.

An S2k guideline is a consensus-based ("k") guideline that has undergone a structured process to reach a consensus.

The newly published S2k guideline is available for download on the AWMF online platform.

“Painful disease of the fat tissue” instead of  “edema disease”

The S2k guideline now no longer focuses on the treatment of edema, but rather on pain in the form of pressure, touch, spontaneous pain and a feeling of heaviness. A disproportionate increase in fatty tissue on the extremities without these corresponding pain symptoms should not be included under the diagnosis of lipoedema.

Diagnosis​

The criterion of “bulging” fat tissue, which was frequently used in the past, should not be used for diagnosis due to its lack of validity.

Staging and progression

The staging of morphology, which was previously used in the literature, no longer appears in the new S2k guideline, as it should not be used as a measure of the severity of the disease. A (new) staging system for symptoms does not yet exist. Lipedema should now not be regarded as a progressive disease in principle, as progression depends on various factors.

Compression therapy

As lipedema is primarily neither an edema disease nor a clinical picture with venous or lymphatic dysfunction, the main focus of compression therapy is on subjective symptoms and pain.

The primary aim of compression therapy for lipedema is therefore to reduce pain and other subjective symptoms. When combined with edema of other origins, the associated edema formation and reduction is also favorably influenced.

Compression therapy for lipedema can initially be carried out with medical compression stockings (MCS), compression bandages (CB) and medically adaptive compression systems (MAC). In long-term treatment, MCS should be preferred in routine cases. Lipedema can generally be treated with round or flat-knit MCS. In the case of large circumferential changes to an extremity and in the case of deeper tissue folds, a flat-knit quality should be prescribed, as round-knit material is unsuitable for these anatomical conditions. A rigid assignment of a compression class to the diagnosis of lip­edema should not be made, as the aim of compression therapy is to improve the subjective symptoms, in particular the pain.

If compression is not applicable in individual cases or does not lead to a reduction in pain on its own, the main symptom of pain can be treated with additional lymphatic drainage in combination with other therapy techniques. Manual lymphatic drainage does not aim to reduce volume, but rather to modulate the C-fibers which serve the perception of pain.

Other therapy techniques

Since exercise programs and movement in compression are an important element of pain reduction, they should be included in the overall therapeutic concept.

Manual lymphatic drainage in combination with other therapy techniques should be considered to improve the quality of life (QoL).

Psychosocial therapy

Psychological disorders can affect the symptoms and quality of life of lipedema patients and should be taken into account in the diagnosis and treatment of lipedema. These include, for example, eating disorders, depression and post-traumatic symptoms following violence and abuse. An interdisciplinary therapeutic approach should be pursued.

Nutrition and weight management

The new guideline devotes considerably more space to recommendations relating to weight management and the improvement of symptoms. Patients should be informed that if they are also overweight or obese, leg volume can also be reduced by losing weight with an appropriate diet.

Short-term diets should be avoided. Instead a permanent switch should be made to an individually adapted, healthy diet with the aim of maintaining a healthy body composition and reducing pain and discomfort. pain and discomfort.

Surgical treatment of lipedema

Liposuction should be used as the surgical method of choice for the lasting reduction of the affected subcutaneous fatty tissue of lipoedema on the legs and arms. Lipedema cannot be cured by liposuction. Liposuction can permanently alleviate pain and improve quality of life.

References:  S2k-Leitline: https://register.awmf.org/de/leitlinien/detail/037-012 ; G. Faerber. Vasomed, 36. Jahrgang_1_2024