Version July 2025
INTRODUCTION —
Lipedema is defined by an International Consensus as "a chronic condition characterized by a disproportionate increase in adipose tissue and pain in the lower extremities, and sometimes, the upper extremities of females" [1]. Lipedema is often confused with or misdiagnosed as other conditions such as obesity or lymphedema.
The clinical features of lymphedema, which can coexist in patients with obesity and who may also have underlying lipedema, are reviewed separately. (See "Pathophysiology, classification, and causes of lymphedema" and "Clinical features, diagnosis, and staging of peripheral lymphedema".)
INCIDENCE AND PATHOGENESIS —
The true incidence of lipedema is unknown [1]. Patients with lipedema were historically erroneously diagnosed with lymphedema and referred to lymphedema programs. Two studies reported that 4 percent of individuals referred with primary "lymphedema" actually had lipedema [2,3].
Lipedema was first described by Allen and Hines in 1940 [4]. They subsequently reported their series of 119 patients in 1951 [5]. Although individuals were referred with a diagnosis of "lymphedema," they noted a unique phenotype. Unlike patients with lymphedema, subjects were always female, both lower extremities were affected, the feet were spared, and the patients did not have infections [5]. They termed the condition "lipedema" because some patients also exhibited minor swelling [5]. However, because "edema" was included in the name of the disease, a misconception has existed that swelling is a primary component of the disorder, causing confusion and mislabeling as lymphedema [1].
Lipedema is a chronic condition with symmetric deposition of subcutaneous adipose tissue disproportionately in primarily the lower extremities. On magnetic resonance imaging (MRI), the subcutaneous fat is circumferentially increased. Histologic evaluation shows adipocyte hypertrophy, increased intercellular fibrosis, and the presence of an immune cell infiltrate [6,7]. Unlike lymphedema, dermal thickening and fibrosis are not present in patients who are not also obese [2]. Reported pain may be related to inflammation from increased numbers of macrophages, hypoxia, and fat necrosis [1]. Because of the association with pain, International Consensus Guidelines have recommended renaming the disorder "lipalgia syndrome" [1].
The etiology of lipedema is not well understood. The disease appears to be caused by a germline mutation because it follows an autosomal dominant mode of inheritance with incomplete penetrance (16 to 44 percent of patients report their mothers also had the condition) [2,5]. Potential candidate genes associated with lipedema include VEGFA, GRB14-COBLL1, and LHFPL6 [8,9].
Although not a classic clinical feature of lipedema, edema may develop related to other concurrent conditions (eg, lymphedema, inflammatory changes). A significant proportion of individuals with lipedema are overweight or obese (>90 percent [1]). Based on modern understanding, obesity impairs lymphatic function, and when body mass index (BMI) exceeds 30, lower extremity swelling is likely to develop [10-12]. Patients with swelling in the original reports by Allen and Hines likely had a higher BMI. Individuals with a BMI >30 and lower extremity swelling with normal lymphatic function by lymphoscintigraphy have what is termed "obesity without lymphedema" (OWL) [13]. Subjects with a BMI >40 and abnormal lymphatic function have "obesity-induced lymphedema" (OIL) [13]. Consequently, patients can be primarily affected by lipedema, gain weight, and then secondarily develop swelling (OWL or OIL) [13]. (See "Pathophysiology, classification, and causes of lymphedema", section on 'Obesity'.)
CLINICAL FEATURES —
The onset of lipedema may be appreciated by some patients as beginning during puberty, although the onset can occur later [2]. Individuals commonly state that they experienced normal or slightly increased weight, and their lower extremities became painful, enlarged, and disproportionate with the rest of their body. They often report their mothers exhibited a similar phenotype.
Classic features — "Classic" clinical features of lipedema include the following [1,2,5]:
●Only females are affected
●Symmetric bilateral increase in the size of the lower extremities (buttocks, hips, thighs, legs)
●Prominent malleolar fat pads
●Normal feet
●No infections
●Pain in the affected areas at rest
●Pain on palpation of the affected areas
●Positive family history (ie, other female family members with the same phenotype)
●Psychosocial distress
In the author's experience, patients notice easy bruising in the lower extremities, and some studies have noted subjective reductions in bruising following intervention [14]; however, objective measurement of reported bruising has not been validated [15].
International Consensus Guidelines do not include edema in the diagnostic criteria for lipedema [1]. If swelling is present, it is secondary to localized inflammation caused by the diseased fat or related to other conditions (eg, increased body mass index [BMI], orthostatic edema, lymphedema). In the originally reported series, only 25 percent exhibited edema that was "minor" [5]. Many subjects had obesity, and it is possible these were the individuals with reported swelling. In a later review, 8 of 9 patients did not have obesity and only had minor focal edema of the pretibial area [2].
Lipedema generally does not exhibit significant progression in patients who maintain a normal BMI. However, if patients gain weight, their lymphatic function becomes compromised, resulting in edema. As many as 80 percent of patients with lipedema have a BMI >30 [1]. The higher the BMI, the more likely it is that irreversible lymphedema will develop [13]. As BMI increases, patients enter an unfavorable cycle of increased subcutaneous adipose deposition that occurs with both obesity and lymphedema, causing progressive lower extremity enlargement. (See "Pathophysiology, classification, and causes of lymphedema", section on 'Obesity'.)
Physical examination — A complete physical examination should be performed including all extremities. In patients with lipedema, examination of the lower extremities shows disproportional fatty tissue variably extending from the hips to the ankles with sparing of the feet (picture 1). Classically, there is a cutoff at the ankle with prominent extra malleolar adipose tissue. Patients may experience bruising of their affected areas and palpation may be painful. The skin proximal to the second toe can be pinched (ie, negative Stemmer sign), indicating normal lymphatic function [16]. For those with upper extremity involvement, findings are similar, with hands spared.
If the individual with lipedema has a BMI >30 kg/m2, and especially for BMI >40 kg/m2, it may be challenging to identify the classic signs of lipedema on physical examination (ie, lower extremities that are disproportionate to the rest of the body, no involvement of the feet, negative Stemmer sign) because of the confounding clinical features of obesity, with or without lymphedema.
Stages and types — Some authors categorize lipedema into stages and types [17]; however, we and others prefer not to do so because these criteria are limited, and making a determination is confounded by obesity [1,2,5,18]. In addition, the amount of excess subcutaneous fatty tissue and pain do not correlate with one another [1].
DIAGNOSIS OF LIPEDEMA —
The diagnosis of lipedema is based primarily on history and physical examination. Two criteria define lipedema and include a disproportionate, symmetric increase of adipose tissue predominantly in the lower extremities and associated pain in the affected areas [1]. (See 'Clinical features' above.)
Whether additional diagnostic evaluation (eg, lymphoscintigraphy, imaging) is done depends on the clinical history, particularly the age at onset and presentation, and the history and severity (ie, body mass index) of obesity and any associated lymphedema. (algorithm 1).
●Female adolescents or young adults are more likely to present with "classic" clinical features (ie, excess disproportionate fatty tissue and pain in this tissue). The patient typically notes that by age 18 the size of their lower extremities was out of proportion with the rest of their body and that they were either a normal weight or mildly overweight.
●In adults, historical information may also suggest a diagnosis of lipedema. However, if the individual has a body mass index (BMI) >30 kg/m2, and especially a BMI >40 kg/m2, the classic physical examination signs of lipedema may not be present or more difficult to identify.
Adults with increased fatty tissue, even if disproportionate, who do not have associated pain (ie, painless lipohypertrophy) are unlikely to have lipedema.
Lower extremity imaging — If the diagnosis of lipedema is clear based on clinical features (ie, lower extremities out of proportion with the rest of the body, no involvement of the feet, negative Stemmer sign (see 'Classic features' above)), imaging is not mandatory. However, imaging may be obtained if the diagnosis is not clear, for counseling purposes, or for operative planning.
Lymphoscintigraphy — Lymphoscintigraphy can be obtained for patients with a BMI >30 kg/m2 to identify lymphatic dysfunction and help differentiate lipedema from obesity without lymphedema (OWL) and obesity-induced lymphedema (OIL) (algorithm 1). (See "Clinical features, diagnosis, and staging of peripheral lymphedema", section on 'Lymphatic imaging'.)
Lymphoscintigraphy is 96 percent sensitive and 100 percent specific for lymphedema [19]. In patients with lipedema, lymphoscintigraphy may demonstrate normal lymphatic function, provided the patient's BMI is less than 40 kg/m2 [13]. Using lymphoscintigraphy and maximum BMI history will help differentiate lipedema from OWL and from OIL (algorithm 1). (See 'Differential diagnosis' below.)
●A normal lymphoscintigram (ie, functional lymphatic system) can occur with lipedema or OWL. If a patient presents with classic clinical features (see 'Classic features' above), they are likely to have lipedema, whereas if those features are absent, the diagnosis is likely to be OWL. (See 'Obesity' below.)
●An abnormal lymphoscintigram in a patient with a normal BMI history means the individual has lymphedema. Lymphatic dysfunction in a patient with a BMI history >40 kg/m2 indicates the patient has OIL. If suggestive clinical features are also present, they may have comorbid lipedema. (See 'Incidence and pathogenesis' above and 'Lymphedema' below.)
Magnetic resonance imaging — MRI may be useful in supporting a clinical diagnosis or for preoperative planning. In individuals with lipedema, MRI exhibits symmetrically increased circumferential subcutaneous adipose tissue without evidence of muscle or bony overgrowth.
DIFFERENTIAL DIAGNOSIS —
Lipedema is a chronic condition characterized by a disproportionate, symmetric increase in adipose tissue primarily in the lower extremities and associated with pain. Conditions commonly confused with lipedema include obesity and lymphedema.
Other chronic conditions associated with pain in the extremities also need to be considered. These are reviewed separately. (See "Overview of soft tissue musculoskeletal disorders" and "Overview of and approach to the idiopathic inflammatory myopathies" and "Clinical manifestations and diagnosis of polymyalgia rheumatica".)
Obesity — The most common condition mistaken for lipedema is otherwise healthy, enlarged lower extremities with no associated pain in patients who are overweight or obese (table 1). In two large European Centers focused on lipedema, 76 to 82 percent of female patients referred with a diagnosis of "lipedema" were overweight but did not have the condition [1].
Enlarged lower extremities can have a similar appearance. However, unlike obesity, lipedema affects the lower extremities bilaterally; classically, the remainder of the body is unaffected. By contrast, patients with obesity have generalized enlargement of their feet, abdomen, and other areas of their body.
As body mass index (BMI) increases, lymphatics may become damaged and swelling may worsen. When lymphatic dysfunction occurs, patients will develop additional subcutaneous adipose and enter a worsening cycle of weight gain and lymphatic injury. Patients who develop obesity-induced lymphedema (OIL) can further develop localized areas of soft tissue overgrowth of their thighs and genitalia (termed massive localized lymphedema) [20]. The fundamental treatment of obesity is weight loss. (See "Obesity in adults: Overview of management".)
Lymphedema — The second most common condition mistaken for lipedema is lymphedema (table 1) [21]. Lymphedema results from malformed lymphatics (ie, primary lymphedema) or from injury to a normally developed lymphatic system (ie, secondary lymphedema (see 'Obesity' above)).
●Primary lymphedema affects the lower extremities (90 percent) or upper extremities (10 percent). Thirty-one known mutations have been implicated in primary lymphedema [22]. Primary lymphedema is often an autosomal dominant condition and patients may have a family history. It can affect individuals of any sex. Males most commonly present with bilateral leg edema in infancy, while females typically develop unilateral disease during adolescence [22].
●Secondary lymphedema causes 99 percent of cases of lymphedema and usually results from cancer treatment that includes lymphadenectomy or radiation to the axillary or inguinal lymph nodes. In resource-abundant countries, the upper extremity is the most common site because of breast cancer management. Other causes of secondary lymphedema include trauma, infection, and OIL. (See "Pathophysiology, classification, and causes of lymphedema", section on 'Causes of lymphedema'.)
Lymphedema initially increases extremity volume by high-protein fluid accumulation in the subcutaneous tissue. Over time, the inflammatory fluid stimulates subcutaneous adipose deposition, further increasing the size of the extremity [22]. The feet are nearly always involved and typically are the most severely affected part of the extremity. On lymphoscintigraphy, patients exhibit delayed transit of radiolabeled tracer to their inguinal nodes and/or dermal backflow. Because of the impaired lymphatic system, patients with lymphedema have an elevated risk of developing cellulitis in the affected extremities [22]. Lymphedema is managed with compression therapies including custom-fitted garments, pneumatic pumps, and/or complete decongestive therapy (includes a combination of manual lymphatic drainage and compression wrapping). Patients are also counseled to exercise and maintain a normal BMI. (See "Management of peripheral lymphedema", section on 'Complete decongestive therapy'.)
Patients with symptoms who are no longer responsive to conservative management can be managed operatively. Similar to lipedema, liposuction effectively removes the excess subcutaneous adipose tissue and also can improve the patient's lymphatic function [23]. (See 'Liposuction' below and "Surgical treatment of primary and secondary lymphedema".)
MANAGEMENT —
The goals of management for patients with lipedema are to manage pain, prevent superimposed lymphedema and its related complications, and improve physical and psychosocial function. These are generally accomplished with a combination of conservative measures, which include pain management, proper nutrition, exercise and weight control, psychosocial support, and possibly surgical intervention (eg, liposuction) [1].
Conservative measures
Pain management — Pain service consultation may be beneficial for patients with significant pain symptoms. (See "Approach to the management of chronic non-cancer pain in adults" and "Overview of pharmacologic management of chronic pain in adults".)
Compression therapy might benefit some patients with lipedema through its anti-inflammatory effects [1]. Individuals with a body mass index (BMI) >30 and edema related to obesity or lymphatic dysfunction are more likely to benefit. Those with a BMI <30 and minimal edema are less likely to find compression therapy helpful, and it can worsen pain [2,5]. (See "Management of peripheral lymphedema", section on 'Compression therapy'.)
Psychosocial support — The International Consensus Group on Lipedema advocates for consultation with medical professionals focused on psychosocial well-being and self-management to help with pain symptoms and improve psychological well-being [1]. Self-management strategies may help to improve some of the complications caused by lipedema (eg, chronic pain, overgrowth, difficulty wearing clothing).
Weight control — Patients with lipedema are encouraged to maintain a healthy diet (see "Healthy diet in adults") and participate in regular exercise.
Exercise can benefit patients with lipedema by helping to reduce weight and may also decrease adipose inflammation and enhance psychosocial well-being [1]. We support any type of exercise the patient prefers that maximizes their active engagement. Weight loss can reduce the amount of diseased adipose tissue in patients with lipedema [1]. Although the extremities will remain disproportionately larger than the rest of the body, symptoms can be improved [1]. (See "Exercise prescription and guidance for adults".)
For patients who are overweight or obese, referral to a weight loss center that offers nutrition-based, drug-based, and operative weight loss options (as indicated) can be helpful. For those with a BMI >40, weight loss reduces ongoing injury to their lymphatic system. If the patient has already developed obesity-induced lymphedema (OIL), then reducing BMI <40 is necessary to decrease the progression of lymphedema. Although weight loss in patients with OIL does not cure the disease, it improves lymphatic function [24]. Weight loss also is helpful for patients with a BMI between 30 to 40. Patients with obesity can be referred to a weight loss center to obtain nutritional, drug, and operative strategies for weight loss.
Some patients may benefit from a bariatric surgical procedure, which has been shown to improve lipedema symptoms [1,25]. (See "Bariatric surgery for management of obesity: Indications and preoperative preparation" and "Bariatric procedures for the management of severe obesity: Descriptions".)
Liposuction — Liposuction removes the affected subcutaneous adipose. Based primarily on observational studies, it effectively reduces pain and other symptoms and improves appearance and quality of life [1,26-31]. Patients may elect to proceed with liposuction for symptomatic relief, to improve appearance, or both. (See "Surgical treatment of primary and secondary lymphedema", section on 'Liposuction'.)
Liposuction may be more effective in early-stage lipedema. Performing liposuction on patients with a BMI >40 kg/m2 is associated with increased complications, unfavorable outcomes, and recurrence [32]. Thus, patients with a BMI >40 kg/m2 can be referred to a bariatric surgical weight loss program to help them reduce their BMI prior to liposuction. By contrast, the risks and outcomes are favorable in patients who have a BMI <35 kg/m2. Liposuction can also be considered for very symptomatic individuals with a BMI between 36 and 39 if they have achieved their lowest possible BMI. (See "Bariatric surgery for management of obesity: Indications and preoperative preparation".)
Liposuction generally improves quality-of-life measures. In a prospective study, 511 patients with lipedema were provided with quality-of-life surveys (World Health Organization Quality of Life BREF [WHOQOL-BREF] and the Patient Health Questionnaire 9 [PHQ-9]) [29]. Among those who proceeded with liposuction and completed both surveys before and after liposuction, there were significant improvements in physical functioning, including limitation in walking and occupational disability, quality of life, and satisfaction with appearance.
Prior to surgery, candidates undergo lymphoscintigraphy (if not already done) to evaluate their lymphatic function and MRI to ensure there is extra subcutaneous adipose that would benefit from the procedure (picture 2). The author prefers to operate on one extremity at a time with a minimum of six weeks in between procedures. Staging the extremities allows immediate ambulation and reduces the risk of deep venous thrombosis.
After liposuction, patients are typically discharged to home on the day of the procedure or the day after. Postoperatively, patients are encouraged to ambulate immediately to reduce the risk of venous thromboembolism. The surgical dressing, which consists of gauze and elastic bandages, is changed in the office one week postoperatively. Thereafter, the patients maintain compression (eg, elastic bandages, compression garment) for a minimum of six weeks postoperatively to maximize skin contraction.
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lymphedema".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Lipedema (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Lipedema – Lipedema is a chronic condition occurring in females characterized by a symmetric increase in adipose tissue disproportionally located in the lower extremities, and rarely upper extremities, and associated with pain. Lipedema occurs exclusively in female patients and can follow an autosomal dominant mode of inheritance with incomplete penetrance. (See 'Incidence and pathogenesis' above.)
●Clinical features – "Classic" clinical features of lipedema include the following (See 'Clinical features' above.):
•Only females are affected
•Symmetric, bilateral increase in the size of the lower extremities (buttocks, hips, thighs, legs)
•Prominent malleolar fat pads
•Normal feet
•No infections
•Pain in the affected areas at rest
•Pain on palpation of the affected areas
•Positive family history (ie, other female family members with the same phenotype)
•Psychosocial distress
●Diagnosis and differential diagnosis – The diagnosis of lipedema is based on clinical features including history and physical examination (algorithm 1). Obesity and lymphedema are commonly mistaken as lipedema. Making the distinction between lipedema and obesity or lymphedema can be difficult because patients with lipedema may develop obesity or lymphedema (table 1). Additional evaluation may be needed to differentiate lipedema from obesity or lymphedema. Other chronic conditions that cause extremity pain also need to be considered. (See 'Diagnosis of lipedema' above and 'Differential diagnosis' above.)
•Lipedema – Female adolescent or young adult patients are more likely to present with the classical clinical features. These clinical features may not be present or more difficult to identify if an individual with lipedema has a body mass index (BMI) >30 kg/m2, and especially if BMI >40 kg/m2, because of the confounding clinical features of obesity. Additional evaluation is needed to differentiate lipedema from obesity without lymphedema (OWL) and obesity-induced lymphedema (OIL).
•Obesity – Patients with obesity have generalized enlargement of their body and do not report pain. A patient who presents without classical clinical features of lipedema and shows no evidence of lymphatic dysfunction on lymphoscintigraphy likely has OWL. (See 'Obesity' above.)
•Lymphedema – Lymphedema can be primary or secondary. Primary lymphedema can present as limb swelling in adolescence but is often unilateral and typically painless, whereas lipedema is bilateral, symmetric, and associated with pain. Other etiologies may lead to secondary lymphedema, but these are apparent in the clinical history (eg, trauma, radiation therapy, lymphadenectomy).
Severe obesity (BMI >40 kg/m2) can also cause bilateral lower extremity lymphedema (ie, OIL).
-Abnormal lymphoscintigram in a patient with a normal BMI history indicates the individual has lymphedema and not lipedema.
-Abnormal lymphoscintigram in a patient with a history of BMI >40 kg/m2 indicates the patient likely has OIL, but if suggestive clinical features are also present, the patient could also have had lipedema. (See 'Lymphedema' above.)
●Management – Management of lipedema includes a combination of conservative measures (pain management, proper nutrition, exercise and weight control, psychosocial support) and possibly liposuction. (See 'Management' above.)
•Pain management – Pain service consultation may be beneficial for patients with significant pain symptoms. Compression therapy may benefit selected patients with lipedema (eg, those with edema related to obesity [BMI >30] or lymphatic dysfunction). Compression therapy may reduce pain through its anti-inflammatory effects. (See 'Pain management' above.)
•Psychosocial support – Psychosocial support is an important aspect of the care of these patients. The International Lipedema Consensus group recommends consultation with medical professionals focused on psychological well-being to help patients manage this chronic painful condition. (See 'Psychosocial support' above.)
•Weight control – Patients with lipedema are encouraged to maintain a healthy diet and participate in regular exercise. Individuals with a BMI >40 kg/m2 should reduce their BMI below this threshold to alleviate lymphatic injury. Individuals with a BMI between 30 and 40 also benefit from weight loss. Referral to a bariatric weight loss center that offers nutrition-based, drug-based, and operative weight loss options can be helpful. (See 'Weight control' above.)
•Liposuction – Liposuction effectively removes the pathologic subcutaneous adipose tissue and improves symptoms, physical functioning, and overall quality of life. We offer liposuction to symptomatic patients who are most likely to benefit. This includes patients with elastic skin that can maximally contract and who have a BMI <35 kg/m2; patients with a BMI between 35 and 40 kg/m2 can be treated after achieving their lowest possible weight. (See 'Liposuction' above.)
