Tropical Lymphoedemas: how to make a difference. Dr Claire Fuller MA FRCP

Transcription

1 Tropical Lymphoedemas: how to make a difference Dr Claire Fuller MA FRCP

2 IMPACT OF LOWER LIMB SIMPLE SKIN CARE ON DISEASE BURDEN IN TROPICAL LYMPHOEDEMAS & OTHER LOWER LIMB DISEASES INCLUDING; FILARIASIS PODOCONIOSIS LEPROSY KAPSOSI S SARCOMA Skin barrier funcpon Simple skin care package Evidence for benefit Controversies for integrated care

3 What is skin barrier funcpon?

4 what contributes to skin barrier funcponing? quality of the epidermal cells interacpon between cells, of the epidermis and dermis intercellular substances immune system Skin is a dynamic organ that is conpnuously renewing and altering itself in response to endogenous and exogenous spmuli

5 What can go wrong?

6 NTDs = Neglected Tropical Diseases SIMPLE SKIN CARE IMPROVING QUALITY OF LIFE IN NTDS

7 WHO List June 2017 Neglected tropical diseases 20 categories Buruli ulcer Chagas disease Dengue and Chikungunya - Dracunculiasis (guinea-worm disease) Echinococcosis Foodborne trematodiases Human African trypanosomiasis (sleeping sickness) Leishmaniasis Leprosy (Hansen's disease) LymphaPc filariasis Mycetoma, chromoblastomycosis and other deep mycoses Onchocerciasis (river blindness) Rabies Scabies and other ectoparasites Schistosomiasis Soil-transmi^ed helminthiases Snakebite envenoming Taeniasis/CysPcercosis Trachoma Yaws (Endemic treponematoses)

8 What is simple skin care Washing +- anpseppc Moisturising Simple compression/protecpon Sock Bandage Foot protecpon Boot/ shoe/custom made? ElevaPon at night +- breathing/yoga

9 Very simple materials soap disinfectant moisturiser with anpfungal

10 Simple Management of Lymphoedematous leg Washing daily washing with soap & water & if possible, anpseppc reduces the bacterial load

11 Simple Management of Lymphoedematous leg Emollient moisturising aber washing improves the barrier funcpon sobens the skin prevents cracking reducing the risk of infecpon

12 Simple Management of Lymphoedematous leg ElevaNon of the limb to above hip night Breathing and exercise (yoga?) Improves lymphapc drainage

13 Simple Management of Lymphoedematous leg Compression bandages and hosiery (stockings or socks) Manual lymphanc drainage light superficial massage can greatly enhance lymphapc drainage. Surgery Simple shave excision of hard nodules with secondary intenpon healing works well, even in a resource-poor seeng. Footwear safeguarding the foot and limb robust and protecpve shoes providing protecpon from injury and infecpon ProtecPon from soil (podo)

14 What are we trying to help? Podoconiosis LymphaPc filariasis Kaposi s sarcoma Lepromatous limb DiabePc foot

15 What are we trying to achieve? ReducPon in disease burden Improvement in life quality Lymphoedemas (podoconiosis, lymphapc filariasis & KS) ReducPon in limb size Stop acute episodes of cellulips ADLA ReducPon in spgmapsapon Leprosy PreservaPon of funcponing limb ReducPon in ulcerapon in the neuropathic foot

16 Acute episodes in the swollen limb? CelluliPs acute spreading inflammapon of the skin More common in lymphoedema as the swollen limb is relapvely immunosupressed Swelling leads to dryness and cracking and entry points for infecpon In lymphoedema a^acks are variable Each a^ack further damages lymphapcs and worsens lymphoedema Also known as acute episodes or adenolymphangips ADLA

17 BriPsh Lymphology Society & Lymphoedema Support Network - September 2016

18 PATCH 1 (2+ cellulips a^acks in 3years). penicillin (250mg bd) V Placebo 22% compared with 37% whilst taking the medicanon oedema (lymphoedema) 81 (60%) penicillin 82 (59%) placebo N Engl J Med May 2;368(18): Thomas KS 1, Crook AM, Nunn AJ, Foster KA, Mason JM, Chalmers JR, Nasr IS, Brindle RJ, English J, Meredith SK, Reynolds NJ, de Berker D, MorPmer PS, Williams HC; U.K. Dermatology Clinical Trials Network's

19 WHAT IS ALREADY IN PLACE FOR THE TROPICAL LYMPHOEDEMAS?

20

21 By 2020 minimum package of care: treatment for episodes of adenolymphangips (ADL); guidance in applying simple measures to manage lymphoedema and hydrocele to prevent progression of lymphoedema and debilitapng, inflammatory episodes of ADL; surgery for hydrocele; treatment with anpfilarial medicines to destroy any remaining worms and microfilariae by prevenpve chemotherapy or individual treatment

22 EradicaPon of podoconiosis within our lifepme

23 Aluminium silicates obliterapve endolymphangips

24 podoconiosis Right soil and weather conditions 10% population affected with the gene 1 million in Ethiopia alone Found in the poorest rural communipes shoes unaffordable People have no polipcal voice

25 PrevenPon: Distribute Shoes to Children GenePcally at risk for podo, and addiponal benefits to all others

26 PrevenPon: Distribute Shoes to Children GenePcally at risk for podo, and addiponal benefits to all others Partner with other NTD groups Helminths Snake bite

27 Beyond Drugs shoes are the new bed nets Ethiopia: Aim for Podoconiosis STH, tetanus, snake bite, tungiasis Lymphoedema LF & KS People Power

28 WHAT IS THE EVIDENCE FOR BENEFIT?

29 Podoconiosis EffecPveness of a Simple Lymphoedema Treatment Regimen in Podoconiosis Management in Southern Ethiopia: One Year Follow-Up Mean clinical stage mean difference (95% CI to 20.96) lower leg circumference decreased significantly -2.00cm Mean DLQI 21/30 to 6 (p, 0.001). mossy lesions persisted Catherine Sikorski...& Gail Davey PLoS Negl Trop Dis Nov 30;4 (issue 11) No ADLA aber treatment

30 LymphaNc Filariasis Self care integrapve treatment demonstrated in rural community seeng improves health related quality of life of lymphapc filariasis papents in endemic villages PaPent one day training camps Skin wash and drying care of bacterial entry points using dermatology drugs DemonstraPon of simple yoga and breathing exercises Start & 6 months The disease burden FEVER ODOUR ITCHING ULCERATION WEIGHT OF LIMB DLQI and LF specific QoL tool Aggithaya MG 1, Narahari SR, et al, Acta Trop Jun;126(3):

31 LymphaNc Filariasis Self care integrapve treatment demonstrated in rural community seeng improves health related quality of life of lymphapc filariasis papents in endemic villages REDUCTION IN DISEASE BURDEN 96% 24.2% papents experienced fever during follow up ReducPon in inflammatory episodes from Severe to no problem There was significant relapon between treatment regularity and QoL status (P value=0.003). Aggithaya MG 1, Narahari SR, et al, Acta Trop Jun;126(3):

32 LymphaNc Filariasis Impact of a Community-Based Lymphedema Management Program on Episodes of AdenolymphangiPs (ADLA) and Lymphedema Progression - Odisha State, 2 years ADLA rates decreased Compliance with soap and water washing ADLA with no entry lesions Mues KE 1, Deming M 2, Kleinbaum DG 3, Budge PJ 2, Klein M 3, Leon JS 3, Prakash A 4, Rout J 4, Fox LM 2 PLoS Negl Trop Dis Sep 11;8(9):e3140..

33 LymphaNc Filariasis Efficacy of home-based lymphoedema management in reducing acute a^acks in subjects with lymphapc filariasis in Burkina Faso 1089 papents WHO lymphoedema management: health educapon and washing project between April 2005 and December % (95%CI: ) of the papents had an acute a^ack in the month preceding the consultapon Aber 4 months reduced to 39.1% Acta Trop Sep;120 Suppl 1:S Epub 2011 Apr 4. Jullien P, Somé Jd, Brantus P, Bougma RW, Bamba I, Kyelem D

34 controversies Shoes Compression ProphylacPc anpbiopcs Soap raises PH and should worsen barrier funcpon Washing Soap? AnPbioPcs Glycerine Moisturiser Breathing exercise ElevaPon of foot at night Socks/bandages Shoes/protecPon Shoes/prevenPon

35 Simple measures effecpvely implemented great benefit