A therapist's hands resting on a client's thigh and knee between white sheets during a treatment

Cellulitis risk with lymphedema after cancer

Q: How do I tell cellulitis from ordinary lymphedema swelling?

Lymphedema swelling is usually painless, slow and the same temperature as the rest of the limb. Cellulitis brings red or warm skin, new or worse pain, and often fever, chills, weakness or muscle aches, according to the American Cancer Society. Macmillan adds red streaks running up or down the limb and flu-like symptoms. If any of those are present, treat it as infection until a doctor says otherwise.

Q: Is cellulitis an emergency if I feel otherwise fine?

It is urgent even without a fever. The NLN asks that any suspected infection in an at-risk or swollen limb be treated as an urgent medical event, because prompt antibiotics limit the infection and help prevent lymphedema starting or progressing. Call your doctor or oncology team the same day; if fever or chills develop, get help right away.

Q: Can I still have my lymphatic drainage appointment while the skin is infected?

No. The NLN lists acute infection as a contraindication to manual lymph drainage and to compression bandaging. Treatment waits until the infection has been assessed and treated; then we resume, often with a fresh look at skin care and garment fit.

Q: I have had three bouts this year. Is there anything beyond treating each one?

Yes, and it is a conversation to have with your doctor. The NLN says that for recurrent cellulitis, for example more than three or four episodes a year, prophylactic antibiotics can be considered after risk factors have been optimized. Good lymphedema control and skin care are part of that optimization.

Red, hot, painful skin on an at-risk or swollen limb is a same-day medical problem: cellulitis damages lymphatics and is the best-known lymphedema trigger.

By The Renu lymphatic and massage team · 7 min read

If skin on an at-risk or swollen limb has become red, hot, painful or newly swollen, see a doctor today. Cellulitis is the best-established trigger and accelerator of lymphedema: the National Lymphedema Network says it significantly increases the risk of lymphedema by causing further lymphatic damage and should be treated as an urgent medical event with prompt antibiotics. If you also have a fever or chills, the American Cancer Society says to get medical help right away and to go to the emergency room if you cannot reach your doctor.

If skin on an at-risk or swollen limb has become red, hot, painful or newly swollen, see a doctor today. Cellulitis is the best-established trigger and accelerator of lymphedema: the National Lymphedema Network says it significantly increases the risk of lymphedema by causing further lymphatic damage, and should be treated as an urgent medical event with prompt antibiotics. If you also have a fever or chills, the American Cancer Society says to get medical help right away and to go to the emergency room if you cannot reach your doctor.

Of all the precautions handed out after lymph node surgery, this is the one that has survived every review of the evidence. This page tells you what to look for, why speed matters so much for this particular infection, what to do today, and what lowers the odds of a next time.

What to look for

The American Cancer Society describes cellulitis as a common and serious skin infection that can develop when bacteria get into a cut, break or opening in the skin. Its signs:

Red or warm skin.
Scaly or broken skin.
New or worse pain or swelling.
Signs of infection such as fever, chills, weakness or muscle aches.

Macmillan’s list for people at risk of lymphoedema adds two details worth memorizing: red streaks that run up or down from the area at risk, and flu-like symptoms. Its instruction is to contact your GP straight away if you notice flu-like symptoms, redness or warmth, a new painful swelling, pain or tenderness, red streaks or a high temperature.

The NLN’s diagnosis statement describes non-purulent cellulitis as redness, warmth, swelling and pain, which is a useful four-word check: red, warm, swollen, sore. The confusing part for someone who already has lymphedema is that swelling is nothing new. What is new in cellulitis is the colour, the heat and the pain, often with feeling unwell. If you are unsure whether your swollen limb is infected, how do I know if my lymphedema is infected walks through the comparison.

Why it matters more for you than for most people

Three strands of evidence put cellulitis at the top of the risk list.

In the prospective screening cohort published by Ferguson and colleagues, cellulitis in the at-risk arm was associated with increases in arm volume at P < .001, the same strength of association as axillary dissection itself, in an analysis where blood draws, injections and flights showed no association at all.

Asdourian’s 2016 review of 31 studies on lifestyle precautions concluded that skin infections, and previous infection or inflammation on the at-risk arm, were among the most clearly defined and well-established risk factors for lymphoedema, while most other precautions rested on low-level evidence.

The NLN explains the mechanism and the loop. Each cellulitis episode causes further lymphatic damage, and lymphedema in turn is the most significant risk factor for recurrent cellulitis, because protein-rich stagnant fluid is an ideal environment for bacteria and lymphedema-associated immune compromise makes persistent infections common. Infection and swelling feed each other, which the statement calls a vicious cycle. Breaking it early, on the first episode, is the whole purpose of treating cellulitis as urgent.

What to do today

Call your doctor or oncology team now, not after the weekend. The NLN says prompt antibiotic therapy is essential to limit the infection and to prevent lymphedema onset or progression. The American Cancer Society asks you to report redness, warmth or swelling to your care team.
If you have a fever or chills, get medical help right away. The ACS is specific: if you cannot reach your doctor, go to the emergency room.
Mark the edge. Drawing a line around the red area with a pen lets you and the clinician see within hours whether it is spreading.
Take off compression if the limb is painful or the garment is cutting in, and tell whoever treats you that you normally wear it. Compression bandaging is contraindicated in acute infection, per the NLN, and your garment routine will be rebuilt once the infection is under control.
Cancel your lymphatic drainage session. More on that below.

Lymphatic drainage waits until the infection is treated

The NLN’s diagnosis statement lists acute infection among the contraindications to manual lymph drainage, alongside decompensated heart failure and acute deep vein thrombosis, and lists it again for compression bandaging. So if you have an appointment with us and the limb is red, hot and sore, the right move is to see a doctor instead and let us know. We would rather reschedule than work on an infected limb. When the course of antibiotics is underway and the skin has settled, treatment resumes, usually with a fresh look at skin care and whether the garment fit contributed. The details are at can you have lymphatic drainage during cellulitis.

Lowering the odds of the next one

Cellulitis needs a way in. Most prevention is about keeping skin intact and clean, and both the NLN and the ACS give practical lists.

Every day (NLN): cleanse with mild, pH-balanced products and moisturize regularly to prevent dryness and cracking; if you wear compression, check the manufacturer’s guidance on which lotions are safe, since some products damage the fibres or alter how the garment works. A routine built on this is at daily skin care routine for lymphedema.

When doing things (ACS): wear protective gloves and shoes, apply sunscreen of SPF 30 or higher, avoid extreme heat, keep nails trimmed short and skip professional manicures during treatment, use clean razors, and apply insect repellent. Macmillan puts it in one sentence: protect your skin from cuts, grazes, insect bites and sunburn, and use gloves for household tasks such as cleaning or gardening.

If the skin breaks (ACS): wash any cut, bite or break with soap and water, and call your doctor if it is not healing or shows signs of infection such as warmth, redness, tenderness or pus.

Heat: the NLN advises people at risk, and people with lymphedema, to avoid saunas and to take care with any thermal exposure that could cause a burn, because a burn is a portal of entry for bacteria.

The ACS also lists who is at higher risk of cellulitis in the first place: a weakened immune system, lymphedema, a past history of cellulitis, radiation dermatitis, rashes, skin trauma, pressure sores, poor circulation and tobacco use. If several of those apply to you, the daily routine is not optional.

If it keeps coming back

One episode raises the chance of another, and the NLN gives a threshold for a different conversation: for recurrent cellulitis, for example more than three or four episodes a year, consider prophylactic antibiotics after optimizing risk factors. That decision is your doctor’s to make, but the “optimizing risk factors” part is where a lymphedema therapist contributes: getting the limb volume down, keeping the skin whole and the garment well fitted, and treating the swelling that gives bacteria somewhere to grow. The wider ranking of what reduces lymphedema risk, with cellulitis prevention near the top, is on reducing lymphedema risk after breast cancer.

When to call your doctor, in one table

What you notice	What to do
Red, warm, swollen or painful skin on an at-risk or swollen limb	Call your doctor or oncology team today
Red streaks, flu-like symptoms, fever or chills	Get medical help right away; emergency room if you cannot reach your doctor
A cut, bite or burn that is not healing, or shows warmth, redness, tenderness or pus	Call your doctor
A third or fourth episode within a year	Ask your doctor about prophylactic antibiotics and ask your lymphedema therapist to review the limb

The Learning Centre’s when to seek medical care page covers the other red flags that are not infection.

Where Renu fits in

We are not where cellulitis gets treated; that is your doctor, with antibiotics, today. We are where the limb gets looked after between episodes. Meeghan Mackenzie, our Certified Lymphedema Therapist, treats established lymphedema with complete decongestive therapy, in which skin care and infection prevention are a built-in component rather than an afterthought, and fits compression garments so they protect rather than chafe. If you have had one bout and are frightened of the next, come in once the infection has cleared; the appointment is as much about teaching your hands what to check each morning as it is about ours.

Questions people ask

How do I tell cellulitis from ordinary lymphedema swelling?

Lymphedema swelling is usually painless, slow and the same temperature as the rest of the limb. Cellulitis brings red or warm skin, new or worse pain, and often fever, chills, weakness or muscle aches, according to the American Cancer Society. Macmillan adds red streaks running up or down the limb and flu-like symptoms. If any of those are present, treat it as infection until a doctor says otherwise.

Is cellulitis an emergency if I feel otherwise fine?

It is urgent even without a fever. The NLN asks that any suspected infection in an at-risk or swollen limb be treated as an urgent medical event, because prompt antibiotics limit the infection and help prevent lymphedema starting or progressing. Call your doctor or oncology team the same day; if fever or chills develop, get help right away.

Can I still have my lymphatic drainage appointment while the skin is infected?

No. The NLN lists acute infection as a contraindication to manual lymph drainage and to compression bandaging. Treatment waits until the infection has been assessed and treated; then we resume, often with a fresh look at skin care and garment fit.

I have had three bouts this year. Is there anything beyond treating each one?

Yes, and it is a conversation to have with your doctor. The NLN says that for recurrent cellulitis, for example more than three or four episodes a year, prophylactic antibiotics can be considered after risk factors have been optimized. Good lymphedema control and skin care are part of that optimization.