HSOA Journal of Clinical Dermatology and Therapy Case Study Video Dermatoscopy in Lymphedema - An Additional Tool

Lymphedema is a major cause of morbidity which is associated with physical, psychological and social burdens. The affected limb has skin changes that range from pitting edema to fissures which are associated with infection. We would like to present our experience with the use of videodermatoscopy to identify the various skin changes at a magnification which might help us to prevent and treat infections more effectively.

• Grade I lymphoedema: mostly pitting edema; spontaneously reversible on elevation • Grade II lymphoedema: mostly non-pitting edema; not spontaneously reversible on elevation • Grade III lymphoedema (elephantiasis): a gross increase in volume in a grade II lymphoedema, with dermatosclerosis and papillomatous lesions The 7 stages of classification as given below are clinically based [2]: The feature of stage 1 lymphoedema is: • Swelling is reversible overnight • In stage 1 lymphoedema, the swelling increases during the day and disappears overnight

Stage 2: Swelling is not reversible overnight
The main difference between stage 2 lymphoedema and stage 1 is that the swelling does not disappear without lymphoedema management. The presence of one or more deep skin folds is the main feature of stage 5 lymphoedema Stage 6: Swelling is not reversible overnight. On the surface of the foot (especially the toes), very small elongated or rounded small knobs can be clustered together, giving rise to the peculiar appearance of "mossy foot" Patients with stage 6 lymphoedema) have acute attacks. Almost all these patients have entry lesions between the toes and bad odour. Wounds in the skin are frequently present.

Stage 7:
The features of stage 7 lymphoedema are: • Swelling is not reversible overnight. The patient is unable to adequately or independently perform routine daily activities such as walking, bathing, cooking, etc.
These skin changes are a result of stagnation of lymph, inflammation leading to fibrosis. This also leads to inability to care for the affected limb leading to a vicious cycle of infection, inflammation and further deterioration of the skin condition.
Emphasis on management of lymphedema is in the treatment and prevention of infection of the limb, the main source of which is the fissures in the skin through which ascending lymphangitis is noticed.
Even though most of the skin changes are visible through the naked eye, videodermatoscopy may help for accurate assessment of the skin changes and possible sites of future infection may be identified earlier due to higher magnification, thus leading to better management of the patient.

Materials and Methods
This is a case report of a 29 year female patient admitted in plastic surgery department in the month of August 2019, with h/o swelling of the left lower limb since 16 years. On assessment and thorough evaluation, the patient was diagnosed with chronic primary lymphedema of left lower limb with secondary grade 7 skin changes (WHO grading) with multiple fissures over the affected limb ( Figure 1). She also had foul-smelling serous discharge from the limb.

Result
In our case, we have done serial videodermatoscopy. The changes noted included deep fissures in some areas with scaling of the skin.
Large scabs over various areas. We noticed that our patient had dryness of the skin which was managed. Improvement was noticed by the healing of the fissures over the skin and was recorded using the videodermatoscope.

Discussion
Videodermatoscopy is an evolved version of dermatoscopy. It is performed by a video camera equipped with opticfibers and lenses that allow magnifications rangingfrom 4x to 1000x. The images are visualizedon a monitor and stored using a specific software ona personal computer.This helps to identify and compare changes over time [3].Videodermatoscopy has great potential in differentiating various dermatological conditions and in the differential diagnosis of pigmented skin lesions, including some inflammatory diseases, cutaneous parasitoses like scabies, hair and nail abnormalities, various vascular lesions. In several disorders, it may be useful in differential diagnosis, prognostic evaluation, and in evaluating the response to treatment [3].
In lymphedema, the videodermatoscope not only helps in recording the progress of the skin changes with serial images, it also helps in identifying potential sites of entry of infection by accurately identifying the deep fissures [4], areas of dryness, or fungal infection which    can then be treated appropriately. Also, it is valuable in identifying a possible source of infection which will help in preventing serious infections and the vicious cycle of skin thickening and more fissures leading to repeated infections.
It also helps in identifying and diagnosing the dreaded complication of lymphedema i.e., lymphangiosarcoma [5].

Conclusion
Our experience with videodermatoscope in lymphedema has shown that it can be used in the armamentarium of the investigation modalities to record and follow-up the skin changes during the course of the disease. Further regular evaluation may also lead to a classification system for skin changes may be formulated. However larger studies are required to emphasize the use of videodermatoscopy in all cases of lymphedema during evaluation.