Ask Dr. Peter Mortimer

Areas of Expertise:
  • Breast cancer related lymphoedema
  • Genetic basis of primary lymphoedema
  • Lymphatic spread of cancer eg melanoma

Professor Peter Mortimer trained in Dermatology in Sheffield and Oxford. He was appointed 'Physician to the Skin Department' at St George's and consultant skin physician to the Royal Marsden Hospital since 1986 and has been Professor of Dermatological Medicine to the University of London since 2000. Interest in lymphatics began in Oxford where he undertook his thesis on 'the measurement of skin lymph flow'. Current research is focused on breast cancer related lymphoedema, the genetic basis of primary lymphoedema and lipoedema as well as melanoma spread by lymphatics. He has over 240 publications cited on PubMed. He has been Chief Investigator on research programme grants from The Wellcome Trust, British Heart Foundation and Cancer Research UK. His clinical practice deals almost entirely with chronic oedema, lymphoedema, lymphatic malformations, lymph-related disorders and lipoedema. He is a founder of both the Lymphoedema Support Network and British Lymphology Society and appointed the first Clinical Training Fellow in Lymphovascular Medicine in the UK.


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  1. Aggravation or new incidence?
    Question (Winter, ):
    • Dear Prof. I had bilateral axilla removal in 2002. I have had lymphoedema in left arm since that time. I was diagnosed with it in my right arm in 2016.(14 years on). Is this a new incidence or is it an aggravation of a general latent condition in your opinion? Is it always latent when you have axilla removal or is it dependent on external factors plus genetic disposition? Thanks.

    Answer:
    • Sep 2018

      As per Dr. Mortimer-
      Thank you for your enquiry. Removal of even one lymph gland from the armpit (axilla) increases the risk of lymphoedema. Onset of lymphoedema after lymph node removal is variable. It can be immediate or may be delayed. The reason is not always clear. Therefore, I suggest onset in your right arm could have occurred at any time. Factors like infection or trauma (accidental or from further surgery) often trigger the onset. I also believe there is a genetic predisposition but there is currently no evidence to confirm that view.

      Hope this response is understandable

  2. LVA surgery
    Question (Simon, ):
    • I have recently been diagnosed with secondary Lymphoedema due to a biopsy in 1992. My left leg is affected and I’m using compression tights to try and control it but at the age off 44 and a fit person who likes to run when possible I’d like to look at surgery if possible. The LVA I’ve seen offered through a private practice in Oxford looks to identify where the blockage is and bypass the flow. This surgery is relatively new but not uncommon in the private sector, I’m unsure of the nhs option. Do you have any knowledge on the success rates as it’s an expensive option? Many thanks Simon

    Answer:
    • Aug 2018

      Dear Simon,
      Apologies for delay but have ben on holiday.
      I am very familiar with the Oxford Lymphoedema Practice team. They have far more experience of LVA surgery than anybody else in the UK. Their results are as good as any published data. By that I mean that the microsurgery can improve swelling but probably by no more than 15-20% on average. It is not a cure and most patients still have to wear a compression garment. For those patients who suffer recurrent cellulitis it also appears to reduce infection rates.
      The Oxford team have tried to get the procedure approved on the NHS but they have failed on many occasions. Occasionally it has been done on the NHS at Chelmsford hospital.
      Hope this helps

      Professor Peter Mortimer

  3. SAPL
    Question (Nina, ):
    • Hi I have primary lymphoedema in my left leg which occurred during pregnancy 15 years ago. I have regular MlD but am looking at surgery. In your opinion would you recommend having VLNT and have you seen positive results from it. If so who would you recommend I used? Thanks NIna

    Answer:
    • May 2018

      Dear Nina,

      By VLNT I presume you mean vascularised lymph node transfer, otherwise known as autologous lymph node transfer.
      The jury is still out as to how effective this surgery is. The average volume reduction is less than 10% so it will not cure your lymphedema, furthermore there is a small risk of causing lymphedema in the region from where the lymph nodes are taken. Therefore proceed with caution. Recommendations regarding who to see depends on where you live.
      Thank you for the enquiry

      Professor Peter Mortimer

  4. Lymphoedema in the stomach
    Question (Suzejo, ):
    • This is a question from the UK, I am so sorry to be a bother to you but I just can't seem to get any answers from the UK so in sheer despiration I've had to come and ask you this ... please can you give me any information on Lymphoedema in the stomach .. my Lymphoedema Clinic have told me that they will no longer deal with me now that I also have Lymphoedema in the stomach (I also have Bi-Lateral leg Lymp hoedema .. they have stated to me in a letter that 'they only do legs' ... I have now been without any form of treatment since last August ... I don't know what to do ... my legs are getting worse as is my stomach and now also my buttocks. .. please can you tell me if there's anything at all I can do to help myself Many Thanks SuzeJo

    Answer:
    • Apr 2018

      Dear Sue Jo,
      Thank you for your enquiry to LE&RN;. Much depends on what you call “lymphedema in the stomach’ as I doubt anybody could diagnose lymphedema of the actual stomach. If you mean lymphedema of the abdominal wall, then that is probably linked with your leg oedema and that would be treated in the same way i.e. massage and compression (abdominal binding), but investigation to find out why it is getting worse would be sensible. If you mean lymphedema of the internal organs then that needs specialist investigation. The St George’s Hospital lymphedema clinic in London is experienced in undertaking such investigations and would be prepared to see you if your lymphedema clinic referred you.
      (.(JavaScript must be enabled to view this email address)).

  5. Self tanning lotions
    Question (Angela, ):
    •  I have primary lymphedema in my right leg. My husband won a trip to Hawaii with the company he works for. Would it be ok to use a self tanning lotion on my leg that has lymphedema? Thank you, Angela

    Answer:
    • Apr 2018

      Dear Angela,

      Yes, I am sure that use of a self tanning lotion would be safe. These products have an active ingredient which combines with dead cells on the surface of the skin to create the colour. It naturally disappears after a few days. What you might find is that your lymphoedema leg goes a different colour from you other leg due to the thicker skin in lymphoedema.
      Therefore I suggest you do a trial before you go

      Professor Peter Mortimer

  6. Lymphovenous Malformation 30 mth baby boy
    Question (Puneet, ):
    • My son was misdiagnosed at birth with a subcutaneous haemangeoma in November 2015 on his left lower thigh. However, following a flare up due to infection in July 17 & Feb 18, he was sent for an MRI which led to an assessment of extensive Lymphovenous malformation. Plastics department said that they cannot perform surgery due to size of malformation. The Interventional radiology department is to perform a biopsy tomorrow. Following that we are to receive treatment options. My questions are: what treatments are there for this condition and what are the risks? Is this condition treatable? is there a specialist hospital/ consultant that we should be referred to given we think that the current practitioners have not got the relevant experience? How can we push for referral to the experts? we are willing to travel (live in Birmingham).

    Answer:
    • Apr 2018

      Apologies for delay but I have been away without a computer.
      Your son’s malformation may well be purely lymphatic and not lymphovenous as it is often impossible to distinguish between the two.
      I would not recommend biopsy as that may risk infection, poor healing, lymph leakage and, besides, it is very unlikely to change management.
      Surgery is also unlikely to solve the problem as it is very difficult to remove these malformations (birthmarks) and they can simply return. If they cause no symptoms I often do nothing. If they have quite large cysts containing lymph then injection sclerotherapy by an experienced radiologist is probably best (bit like injecting varicose veins).
      happy to see at St George’s in London

      Professor Peter Mortimer

  7. Dry Skin
    Question (Kimber, ):
    • I have had lymphedema in my left leg for almost 20 years. The skin around my toes has been dry for some time and has gotten much worse in recent years. I recently began applying Eucerin lotion morning and night. It seemed to help for a while, but now the skin seems to be getting even more cracked and dry and I don't know what to do! Do you have any tips for reversing and preventing this? Thank you!

    Answer:
    • Mar 2018

      As per Dr. Mortimer
      Answer:
      The first consideration must be for a fungal infection and there would be no harm in buying terbinafine (Lamisil) cream and applying at night for 2 weeks. More likely is dryness related to the hardening of skin associated with the lymphoedema skin changes plus effects of cold winter weather (assuming you are in northern hemisphere). 25% urea heel balm (Flexitol) would be worth using as well as bandaging the toes at night if they are swollen

  8. Joyce
    Question (Joyce, ):
    • Prof. Mortimer, reading your posts for the first time on this site(LSN member UK, and secondary lymphoedema sufferer for 13 years). Interesting reading your take on surgery care for lymphoedema patients concerning tourniquets. Two years ago, I had a cardiac arrest at home(one of the lucky ones, I survived!) I was taken to the Freeman Hospital in Newcastle, and had an angioplasty and stent insertion. As we are "trained" to do, I mentioned that I had lymphoedema and therefore shouldn't have treatment on my affected right arm(crazy when my life was at stake, but you do this automatically). They said "don't worry, we can treat cellulitis if it happens!" I had an an incision in my right wrist, and the angioplasty followed. They then fitted an extremely tight plastic tourniquet to seal the artery. I watched it closely for 24 hours or there abouts, expecting problems. Next day, it was removed, and all was well. No effects whatsoever! Lucky or what?

    Answer:
    • Oct 2017

      Dear Joyce
      Thank you for your enquiry
      First of all I cannot criticise your doctors one bit as they quite rightly prioritised and your lymphedema came a distant second when it was a matter of life and death!
      It is true to say that the risks of worse swelling or cellulitis following a sterile puncture are extremely small but if you happen to be the one who gets that complication then it is not acceptable.
      As for tourniquets, again, there is a theoretical risk of worse swelling because of the sudden flush of blood and fluid into the arm when the tourniquet is released but as with a blood pressure cuff that risk is very small.
      I would not describe you as lucky to have had a cardiac arrest but you would have been very unlucky to have suffered worse lymphedema

  9. Fluid under armpit towards chest
    Question (Maryam, ):
    • My dad who is 73, had shingles in July 2016. This resulted in neuropathic pains, which now has lasted a year. Nothing helps for pain relief, but what I am enquiring about is a swollen area filled with fluid under his armpit. It came after the shingles. Doctors in Holland are not sure what it is. He had physio for it, which has not reduced or changed it.It causes pain when he walks or moves. Also his skin remains extremely sensitive. Is he at risk for infection? Will the fluid stay or solidify? What is it? He never had this before. In your expertise, could you please advise me what this could be and which specialist should he refer himself to? He does take meds as he had a heart attack 3 years ago. He does not drink, eats healthy, cycles and walks. I live in the UK. He lives in Holland. Thank you. 

    Answer:
    • Sep 2017

      Thank you for your enquiry
      It is difficult to give a diagnosis without seeing and examining your father. Shingles does not cause a lymph problem. He needs an ultrasound examination or a CT to determine the nature of the swelling so that the correct treatment can be given.
      The skin will remain sensitive because of the nerve damage from the shingles.
      Your other questions are all dependent on the diagnosis.
      If he is in Holland and his doctors think this is a lymph problem then I suggest he consults with Dr Robert Damstra in Groningen
      Sorry not to be more help

  10. Primary or Secondary
    Question (Chrysanthi, ):
    • Dr Mortimer I have developed lymphedema on both ankles at the age of 18. I am healthly and do not suffer from any other condition. Nobody in my family has this condition but I need to identify if It is primary or secondary Lymphedema as this increases the chances of giving birth to a child with the symptom. Is there any specific tests that determines if my condition is primary or secondary?

    Answer:
    • Jul 2017

      As per Dr. Mortimer-


      A: This is likely to be primary lymphoedema (PL) because of the age of onset and because there has been no known damage to the lymph system. Many forms of PL are not inherited but the exact risk to offspring is dependent on the type of PL you have. This can only be determined through an expert who can characterise the type of primary lymphedema you have and if appropriate gene testing.

  11. Treatment Advice
    Question (Gaynor , ):
    • Hi. I am asking the question on behalf of a family member. As a result of being diagnosed with cancer of the uterus approx 14 years ago they underwent a full hysterectomy, they subsequently had chemotherapy and radiotherapy. The lymph nodes were removed from the left leg area. Over the past 4 years lymphodema has become an increasing problem down the left leg. A large lump has grown on the inner thigh and treatment is having very little impact. They are under the care of the Christie Hospital but due to this condition being extremely under funded there are very few options. They currently wear a compression stocking every day which is bearable however trying to obtain a second stocking has become impossible as the nurses never get the measurements right. Very frustrating!! They have visited a clinic in London to investigate the possiblity of lymph node transplant but apparently this is not an option as it has been stated there is a lot of scar tissue?? Whatever that means. I would like to know if there is anywhere in the UK that specialised in lymphodema and what does your research suggest for long term treatment? Many Thanks

    Answer:
    • May 2017

      As per Dr. Mortimer-

      The large lump that has grown on the inner thigh is presumably a large lymphoedema fold although without imaging such as ultrasound examination one cannot be sure. Treating lymphoedema folds is difficult and needs very skilled bandaging. It is important to ensure there is no (over)weight issues as that makes these folds more likely to develop, and more difficult to treat. If all else fails one might have to consider liposuction but everything depends on the circumstances of this patient. Reconstructive lymphatic surgery is unlikely to be an option.
      The biggest lymphoedema centre in the UK is at St George’s Hospital in London. The lymphoedema Support Network in the UK (http://www.lymphoedema.org/lsn) should be contacted for advice”

  12. Lymphedema with cellulitis
    Question (Carmen, ):
    • Since uterine cancer diagnosis and treatment 5 years ago, I have had recurring infections. For the past two years I have experienced rapid onset of cellulitis and lymphedema. I am concerned because the cellulitis comes on so quickly as does the swelling. My doctor has me on daily antibiotic but I do not feel any better. Do you have any suggestions? I am frustrated. Thank you.

    Answer:
    • Apr 2016

      As per Dr. Mortimer-

      “Recurrent infections are a common occurrence with lymphoedema.  It is also very common for the effects of the infection to develop rapidly.  Patients can feel fine one minute and within 15 minutes feel ill with chills and flu-like symptoms.  This is because of the effect lymphoedema has on immune cell trafficking and function within the swollen region.  Research has shown that it is not helpful to give antibiotics only when infections occur.  The infections need to be prevented and the recommendation is for prophylactic penicillin.  Advice for patients on this subject can be found at
      http://www.lymphoedema.org/Menu3/Cellulitis Consensus.pdf

  13. Keratosis
    Question (Ken, ):
    • My question regards the skin lesions that appear to be a hyperkeratosis that are commonly seen particularly in cases of lower extremity lymphedema. Are these keratoses similar histologically to actinic keratoses which may develop from overexposure to sunlight? Do they simply represent a hyperplasia of the keratinocytes or a metaplasia of the keratinocytes in which their cell structure undergo change.

    Answer:
    • Sep 2015

      The hyperkeratosis seen with lymphoedema reflects an increase in the horny layer (keratin) on the surface of the skin.  It is related to the increased thickening of the skin which is often called elephantiasis because it represents elephant skin.  The hyperkeratosis is different from a keratosis which is a benign tumour on the surface of the skin usually resulting from sun damage. 

      Therefore the hyperkeratosis seen with lymphoedema is simply an excessive production of mature keratin from normal keratinocytes.  A keratosis is related to a hyperplasia or dysplasia of the underlying keratinocytes which are the cells responsible for producing the keratin.

  14. Air travel
    Question (Dorthy, ):
    • Well I am planning a trip and it takes 24hours to get there. I had the lymph node taken out of one arm pit and bc and I have a compression sleeve and I can wear it just incase but what else should I do. Is there a big risk of my arm swelling. Is there something I should worry about in Thailand, should I take shots.

    Answer:
    • Jul 2015

      Patients with existing lymphoedema do find that it temporarily deteriorates during a flight.  However it should return to its former condition within 24 to 48 hours of arrival providing there are no complications eg infection.  For patients with existing lymphoedema the recommendations are to wear the compression garment, perform regular exercises during the flight, elevate the swollen area as much as is feasible and ensure no dehydration.  The problem with air travel is inactivity and the cabin pressure.  On arrival it is worth undertaking exercise to stimulate lymph drainage.

  15. psorisis & lymphodema
    Question (Anna, ):
    • Having psoriasis flare-ups on my elbow of my bad arm is challenging. The meds for it don't work for long. What advise do you have to keep the flaking & rawness at bay?

    Answer:
    • Mar 2015

      In general lymphoedema does not affect psoriasis and therefore one would treat the psoriasis in the normal way with ultraviolet light therapy as creams are not that effective. Psoriasis could be,in theory, worse on a limb affected by lymphedema because of the alteration to immune cell trafficking from the compromised lymph drainage. Therefore it makes sense to treat the swelling as well as one can and ensure no infection (as infection can exacerbate psoriasis)

  16. Lymphedema with Angioedema
    Question (Joseph, ):
    • 20 years ago was the first time the back of my head swelled up. It would get really swollen, hot and skin was very tight. It would spread all over the back and into the temple region between 4-12 seconds. After a week or two, it would drain down my neck and out my shoulders. This continued a couple times a year, every single year. Last June, the swelling got worse and reached my face, swelling one eye shut. It no longer drains, as the back of my head and both sides of my neck down by the collarbone have big squishy lumps. In August and continuing, both my armpits and down both sides of my body have swollen up and have stayed that way. My arms, fingers, legs, knees, ankles and toes also are a bit swollen. From what I was told by a doctor was that I have Primary Lymphedema with Angioedema. However, other doctors aren't sure because I don't fit in the "norm" of Lymphedema patients since it's affecting my entire body, literally from head to toe. I've seen so many doctors (ENT, Immunologist, Neurologist, Vascular Surgeon, Internalist) and have every single one of them stumped. Do you have any idea or opinion or thought as to what these conditions are that are happening to me? For some reason, the doctors are not coming to any kind of conclusion to my situation. I look forward to hearing your thoughts. Much Thanks, Joe

    Answer:
    • Feb 2015

      I am not convinced from your history that you do have lymphoedema with angioedema.  Angioedema manifests with bouts of swelling which settle within minutes or over a few hours.  It is thought to be allergic but no cause is usually found.  It is certainly inflammatory and will respond to oral steroids.  There are reports in the literature of recurrent angioedema giving rise to lymphoedema.  However under those circumstances the lymphoedema swelling is persistent and usually affects sites such as the skin around the eyes, mouth or ears.  I would agree that your circumstances do not fit in with the norm either for angioedema or lymphoedema and therefore it is difficult through an online response to advise.  My suggestion would be to see a lymphoedema physician if possible.

  17. Surgery on a breast cancer treated arm
    Question (Elizabeth, ):
    • I am a left breast cancer survivor of 9 years. I had a lumpectomy and 3 sentinel nodes removed. I have also had a parathyroid removed ( benign) and have Hashimoto Thyroiditis. I want to undergo a trigger finger surgery on my left hand and am concerned about Lymphedema. The procedure involves a wound and a tourniquet on the arm/hand I have always been advised to protect from such things. Can you comment on the risk and any possible options to lessen the risk? Say if a tourniquet was somehow not used. Is the wound made and the tourniquet used the same level of risk? I don't want to trade a painful trigger finger for Lymphedema and I just don't know how to calculate the risk?

    Answer:
    • Jun 2014

      Thank you for this interesting question.  You are right in saying that guidelines recommend avoidance of needle puncture/surgery/tourniquets in/on the at-risk arm following breast cancer treatment.  The concern is that swelling could be precipitated.  Furthermore there is always the risk of infection (cellulitis) which could also precipitate long-term swelling.

      Therefore in an ideal world one would advise against trigger finger surgery but one has to do a risk/benefit analysis.  If there is no alternative to your trigger finger then you should undergo surgery.  However I would ask your surgeon if it can be done without tourniquet (assuming the tourniquet is around the upper arm or forearm).  It may also be worthwhile covering the period around the surgery with antibiotics although there is no evidence that this is necessary.

      I am afraid I don’t know the risk analysis of inducing lymphoedema but I would expect it to be very low with surgery alone and higher if the tourniquet is added.