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The International Society of Lymphology (ISL) recommends two phases of treatment for lymphedema:

• Acute intensive phase
• Maintenance phase

Acute Intensive Phase

During the acute phase of treatment, therapy is intense and frequent. In this phase, the size of the affected limb is significantly larger than the normal limb (some clinicians set the criterion at 20% larger than the contralateral limb) and the shape may be distorted. Skin changes may include skin folds, papillomatosis, and/or hyperkeratosis. Each therapist or rehabilitation center sets their own treatment schedules which may be as frequent as twice a day, 5 days a week, and may continue for 4 weeks. Approximately 50% of volume reduction may be achieved though CDP.

The objectives in the acute phase of treatment include:

• Reducing the size of the limb
• Stimulating lymphatic vessels in the contralateral limb and trunk
• Stimulating contractility of lymph vessels to improve movement of lymph and break up fibrotic tissue
• Improving the condition of the skin

Treatment consists of a combination of:

• Manual lymphatic drainage
• Skin care
• Gentle exercise, including range of motion
• Compression with multilayered bandages

Maintenance Phase

When the lymphedema stabilizes and the limb returns to its normal size (for some clinicians the criterion is less than 20% larger than the size of the contralateral limb) and the shape of the limb returns to normal and the skin has softened and is predominantly pitting, the second phase of treatment, called the maintenance phase begins. This phase of treatment continues for the lifetime of the patient and consists of:

• Manual lymphatic drainage as needed
• Skin care
• Continued exercise
• Compression with low stretch elastic stocking or sleeve. The ILS notes the importance of employing only trained personnel to do the multilayer wrapping.

The ISL also notes that:

• If using pneumatic compression for treatment, the sequential gradient pump is preferable and treatment must be followed by a low-stretch elastic sleeve. Gentle massage alone is of limited benefit.
• The role of thermal therapy (soaking limb in warm water) remains unclear.
• Elevation of the limb is effective in reducing swelling but should be followed by low-stretch elastic stocking.
• The efficacy of immunologic therapy (intraarterial injection of autologous lymphocytes) is unclear.
• There is no special diet for the patient with lymphedema (such as a low protein diet), but obese patients should lose weight to reduce bulk.
• Psychosocial support and ongoing effort to improve and maintain quality of life for patients with lymphedema is an integral aspect of treatment

During the maintenance phase, the frequency of treatment is reduced and the patient begins wearing a compression garment during the day and a bandage wrap at night. Eventually, the patient may use a compression sleeve or stocking during the day and nothing at night when the limb must be elevated. Otherwise, all other aspects of therapy remain the same (i.e., continued MLD, meticulous skin care, and exercise).

When lymphedema develops in the presence of severe illness, over a period of time the lymphedema may progress to a point of involving more than just the limb and may extend into the trunk of the body. The condition of the skin may deteriorate due to lymphorrhea, where lymph drips out through breaks in the skin, and the patient may complain of heaviness or reduced range of motion or limb use in general. At that point, treatment is more palliative and aimed at symptom relief rather than improving the lymphedema. Treatment consists of the same modalities used for the acute and maintenance phases but is less aggressive and is flexible to meet the needs of the patient.