CHAPTER 44 Treatment of Lymphedema in India
Lymphatic filariasis is the most prevalent form of lymphedema in India and is usually caused by Wuchereria bancrofti and Brugia malayi.
Medical treatment options for lymphatic filariasis include the administration of diethylcarbamazine in combination with albendazole.
Nonfilarial lymphedema typically presents as postmastectomy lymphedema, for which the mainstay of treatment is comprehensive decongestive therapy.
Surgical treatment comprising direct excision with skin grafting offers the best chance of improvement in patients whose lymphedema is refractory to conservative medical management.
Lymphedema is a permanent, progressive, and debilitating condition that develops from dysfunction of the lymphatic system. In India, filarial lymphedema is by far the most common form and is a public health problem for which an organized, national filarial control program is currently underway. Lymphatic filariasis affects 119 million people living in 73 countries; India accounts for 40% of the global prevalence of infection. 1 Indigenous lymphatic filariasis has been reported mainly from Southern India, whereas the Northwestern states are free of indigenously acquired filarial infection.
In India, lymphedema can be discussed in two broad categories: filarial and nonfilarial lymphedema. The justification for this categorization is the high incidence and prevalence of lymphatic filariasis in India to the point that it is endemic and necessitates independent consideration and importance.
In mainland India, the causative nematodes are primarily Wuchereria bancrofti and Brugia malayi, which are transmitted by specific genera of mosquitoes that include Culex quinquefasciatus, Anopheles, and others. B. malayi infection is now reportedly restricted to rural areas of South India (Fig. 44-1).
PAST AND PRESENT
The treatment options for lymphedema are broadly divided into two categories: medical and surgical. It is hard to distinguish between the past and present modalities of treatment because of the degree of intermingling in the various modalities. However, many past methods, such as crepe bandaging, and operations such as flap transfers, are now rarely used.
ELIMINATION OF LYMPHATIC FILARIASIS
Lymphatic filariasis is endemic in India. Consequently, a national filarial control program was launched in 1955 to control this disease. 1 The objectives of the program were to delimit the problem, to undertake control measures in endemic areas, and to train personnel to staff the program. The main control measures were mass administration of an annual single dose of diethylcarbamazine, antilarval measures in urban settings, and indoor residual spray in rural areas. The strategies of this program included vector control, detection and treatment of filarial cases, and delimitation of endemic areas.
In 1997 the World Health Organization and its member states made a commitment to eliminate lymphatic filariasis as a public health problem by 2020 through World Health Assembly Resolution WHA 50.29. 1 The National Health Policy 2002, released by the Ministry of Health and Family Welfare, set the goal of the elimination of lymphatic filariasis in India by 2015. The twin pillars of lymphedema elimination strategy include transmission control and disability prevention and management.
Mass drug administration with an annual single dose of 6 mg/kg body weight of diethylcarbamazine citrate (DEC) tablets in endemic areas resulted in a drastic reduction in the infection rate, microfilaria rate, and insignificant serious adverse effects in patients with lymphatic filariasis. 3