Podoconiosis

what is it and what can we do about it?

Tsige amberbir1
abreham Tamiru1
abebe Kelemwerk1
Tigest Getanhe1 Gail
davey2
1
International Orthodox Christian Charities, Debre Markos Podoconiosis Project, PO Box 81110, Addis Ababa, Ethiopia 2
Brighton & Sussex Medical School, Falmer Campus, University of Sussex, BN1 9PS, UK
What is podoconiosis? are almost always reported from the foot first, and the
Podoconiosis is a type of lower leg swelling swelling progresses from the foot slowly up the lower leg,
(lymphoedema, which in advanced cases progresses to only rarely reaching above the knee (Figure 1). This is in
elephantiasis) found in highland areas of the tropics. It contrast to patients’ reports in LF, where symptoms
has often been confused with lymphatic filariasis (LF), but frequently originate in the groin, and swelling may be
there are several ways of distinguishing the two noticed anywhere in the leg, often above the knee.
conditions (see Table 1). Podoconiosis develops in people Examination of midnight blood for microfilaria, or use of a
(predominantly farmers) exposed over many years to rapid antigen test (Binax ) will help exclude LF if there is
TM

irritant red clay soils because they do not wear shoes 1. doubt. Other diagnoses that should be considered include
These soils are found in highland tropical areas, where leprosy lymphoedema, onchocerciasis lymphoedema,
ancient volcanic deposits have weathered at high altitude granuloma inguinale, lymphogranuloma venereum and
(over 1000m) under conditions of heavy rainfall (over endemic Kaposi’s sarcoma.
1000mm/year). Podoconiosis is therefore associated with Studies have ruled out bacteria, viruses and parasites as a
high elevation, whereas LF is found at lower altitudes at cause of podoconiosis. It is thought to be a geochemical
which transmission of the parasite by mosquitoes can disease on the basis of the identification of mineral
occur. Countries with a high burden of podoconiosis crystals within the lymph tissues of patients, but the
include Ethiopia, Uganda, DR Congo, Rwanda, and precise trigger of the disease is unknown. There is now
Cameroon. Further distinction between podoconiosis and strong evidence of underlying genetic susceptibility , and
2

LF can be achieved through the patient’s account of early endemic communities are usually aware that
symptoms. In podoconiosis, symptoms (aching, burning) podoconiosis clusters in families.
FIG 1: Bilateral, asymmetric, below-knee swelling with mossy changes and nodules.

Podoconiosis – what is it and what can we do about it? continued

FIG 2. Foot hygiene is a key element of podoconiosis management
CHaRaCTERISTIC POdOCONIOSIS LyMPHaTIC
FILaRIaSIS
>1500 m above <1000 m above
Area of residence
sea level sea level
Mean age of 10–20 years 25–30 years
onset
Relation to
Initial symptom Late complication
natural history
Site of first Any part of limb
Toes and foot
symptom except foot
Local Follows swelling Precedes swelling
lymphadenitis of limb of limb
Typical site Distal, below Above and below
of swelling knee knee
TABLE 1: Characteristics used to distinguish podoconiosis and lymphatic filariasis

Recent work has detailed the enormous economic burden of podoconiosis on affected communities.
In a southern Ethiopian zone of 1.5 million inhabitants, where the prevalence of podoconiosis is
known to be 5.4%, the overall cost of podoconiosis was estimated to be in excess of US$16 million
per year. In this zone, where the average income is less than US$100 per year, the direct costs to a
patient are US$143 per year3. Individuals with podoconiosis are highly stigmatized. They may be
excluded from school, rejected by their family, barred from social and religious gatherings, and
banned from marriage to any unaffected individual 4. Siblings of affected individuals are also
frequently barred from marriage into unaffected families

What can we do about it?

Prevention of podoconiosis includes measures to avoid contact with irritant soil through regular
washing and use of protective shoes. Programs are in place in several podoconiosis-endemic areas
to distribute shoes to children with the aim of preventing disease in the future. Recent evidence
suggests that the risk of disease is lower among people who live in houses with covered rather than
bare earth floors, so this may be another prevention strategy.

Treatment follows the general principles of lower limb lymphoedema management, requiring daily
foot washing, use of a simple emollient, bandaging, socks and shoes, and exercises to improve
lymph flow. These measures can result in clinical and quality of life improvements 5. A podoconiosis
follow-up clinic should aim to provide:

Assessment. Record the following patient details: name, contact address, sex, age, occupation,
number of family members, affected family members and age of onset of condition. For each leg
separately, record clinical stage (see Box 1 overleaf), presence of moss, wounds or infection,
greatest circumference of leg below knee, and presence/absence of acute attack (see Box 2
overleaf).
Training in foot hygiene. Demonstration of soaking both feet in a plastic basin with water and
locally-available disinfectant, washing with soap, rinsing with clean water, drying and rubbing in oil
or Whitfield ointment to improve the barrier function of the skin (Figure 2). Arrangements for water
supply and disposal at the clinic site may have to be made.
Training in bandaging. Patients with more swollen legs (often with softer skin, hence called ‘water
bag’ type) will benefit from careful use of short stretch bandages. Demonstrate how to apply the
bandage while the leg is elevated, from the toes to 10cm above the upper limit of swelling,
overlapping by half the width of the bandage each turn (Figure 3). Each patient will need at least 2
bandages for each affected leg, so he or she can wash one set of
Continued overleaf…
Podoconiosis – what is it and what can we do about it? continued

Box 1. Podoconiosis Staging Sheet: Description For Health Professionals

The stages represent severity of disease, and do not necessarily any subsequent stage, depending on the
position of dermal ridges represent the disease process: it is possible, for example, for and nodules in relation
to joints.
an individual to have stage 5 disease but never to have had above-knee swelling. The following terms are
used in the Mossy changes may be apparent, but their presence depends on a
descriptions:range of factors including the use of plastic footwear. Interdigital

maceration and hyperpigmentation are often present at

this stage,
•Dermal nodules: elevated, non-translucent lesions >0.5cm and nail dystrophy almost always present. diameter,
with width approximately equal to length.
STaGE 3
•Dermal ridges: elevated lesions >0.5cm width, with length
greater than widthBelow-knee swelling that is not completely reversible
overnight; knobs/bumps present above the ankle.
•Dermal bands: palpable, but non-elevated ridges
 Persistent swelling that does not reach above the knee.
Mossy changes: round or fusiform, either fluid filled (and hence
Dermal nodules, ridges or bands are seen or felt above
the ankle.
translucent) lesions, or papillomatous hyperkeratotic horny
Tourniquet-like effects are frequently observed at this
stage. Any of
lesions giving the skin surface a rough velvet-like appearance. the other changes mentioned for Stage 2 may
also be present.
STaGE 1
STaGE 4
Swelling reversible overnight.
above-knee swelling that is not completely reversible The swelling is not present when the patient first gets up
in the overnight; knobs/bumps present at any location.
morning.
Persistent swelling that is present above the knee.
Changes such as hyperpigmentation and nail dystrophy are unusual, but may be seen. The swelling is usually
confined beneath Any of the other changes mentioned for Stage 2 may also be
the ankle.present. In addition, signs of lymphectasia may be apparent, particularly on the thigh. STaGE 2
Below-knee swelling that is not completely reversible STaGE 5 overnight; if present, knobs/bumps are
below the ankle Joint fixation; swelling at any place in the foot or leg.
ONLy.
The ankle or interphalangeal joints becomes fixed and difficult Persistent swelling that does not reach above the
knobs or bumps do not extend beyond the
knee. If present, to flex or dorsiflex. This may be accompanied by adhesion and
ankle.
fusion of the toe web spaces, making the toes appear short or
The ‘knobs or bumps’ may take the form of dermal nodules, ridges indistinct. Sensation is preserved. X-rays show
tuft resorption and or bands. Tourniquet-like effects may be observed at this stage or loss of bone density.
bandages while using the other.

Explanation of the need for socks and shoes. Clean socks and closed shoes are vital in preventing
further exposure to irritant soil and for protecting the swollen leg. Some patients will be able to
afford these themselves. If the patient cannot afford to buy shoes, but demonstrates commitment
to self-treatment, they may be considered for subsidized footwear. Shoes large enough for patients
with extensive swelling may not be available locally, so establishing a shoe workshop (staffed by
treated patients) may be the best way to provide shoes and jobs for patients.

Demonstration of elevation and movement. Encourage the patient to perform toe points, ankle
circles and calf raises 2-3 times per day. Elevate the leg whenever possible by raising the foot
end of the bed or resting the foot on a stool while sitting. Both these will assist lymph return.
Nodulectomy. Discrete nodules that are preventing the patient from wearing shoes may be
removed under local anaesthetic. More extensive surgery is not recommended.

Exploration of avenues of other forms of support. This may include individual counselling, support
through patient-led groups or patient associations, vocational training (including shoe-making) and
micro-credit schemes and spiritual support.
Patient-led, community-based treatment. Podoconiosis is relatively simple to diagnose in endemic
areas6, and to manage. Much of the management of podoconiosis can therefore be decentralised
into the community. Experience from northern Ethiopia suggests that engagement of the
community through ‘Community Conversations’ is essential groundwork for decentralised
management. Community Conversations are voluntary discussions held bi-monthly for up to six
months to facilitate the process of change. Typically, ‘master trainers’ train local trainers (often
podoconiosis project personnel), who in turn train facilitators to lead Community Conversations
with other community members. Once a Community Conversation group has met for approximately
six months, they become responsible for
Box 2. Acute attacks.
Acute attacks (acute dermatolymphangioadenitis) are
highly disabling episodes of fever, pain and increased
warmth and swelling of the affected legs. These
attacks often last 4-5 days, and patients are severely
incapacitated by them. They are managed using anti-
pyretics, analgesics (paracetamol or ibuprofen, or
equivalents) and rest.
forming a Community Action Group to coordinate and lead the implementation of the Community
Conversation Action Plan.

The Action Plan commonly includes formation of a group of motivated self-treated patients, to assist
other patients with treatment and to act as ambassadors in their communities, explaining the cause
of the disease and breaking down stigma by demonstrating that it can be both prevented and
treated. Expert patients can enable ‘task-shifting’, promoting good practice among patients so that
the burden on health professionals is diminished. Monthly monitoring of Patient Led Groups and
quarterly evaluation is recommended. Another common activity of the Community Action Group is
the development of a school health program focussing on the disease awareness and prevention
among students. School health programs may evolve into sites of shoe distribution for disease
prevention.

Summary
Although podoconiosis has been under-recognised for many decades, the experience of a number of
projects within Ethiopia suggests that the disease is one that can be relatively easily controlled given
dedicated community mobilisation. A national forum, the National Podoconiosis Action Network
(NaPAN - http:// www.napanethiopia.org/) has been developed to coordinate efforts against
podoconiosis in Ethiopia, and a global initiative (Footwork – http://www.podo.org) to raise
awareness of and coordinate partnerships against podoconiosis at international level.

References
1. Davey G, Tekola F, Newport M. Podoconiosis: non-infectious geochemical elephantiasis. Transactions of the Royal Society of Tropical
Medicine & Hygiene 2007;101:1175-80.
2. Tekola Ayele F, Adeyemo A, Finan C, Hailu E, Sinnott P, Diaz Burlinson N, et al. The HLA class II locus confers susceptibility to
podoconiosis. New England Journal of Medicine 2012;336:1200-08.
3. Tekola F, HaileMariam D, Davey G. Economic costs of endemic non-filarial elephantiasis in Wolaita Zone, Ethiopia. Tropical Medicine &
International Health 2006;11(7):1136-44.
4. Yakob B, Deribe K, Davey G. High levels of misconceptions and stigma in a community highly endemic for podoconiosis in southern
Ethiopia. Transactions of the Royal Society of Tropical Medicine & Hygiene 2008;102:439.
5. Sikorski C, Ashine M, Zeleke Z, Davey G. Effectiveness of a Simple
Lymphoedema Treatment Regimen in Podoconiosis Management in Southern Ethiopia: One Year Follow-Up. PLoS Neglected
Tropical Diseases 2010;4(11):e902.
6. Desta K, Ashine M, Davey G. Predictive value of clinical assessment of patients with podoconiosis in an endemic community setting.
Transactions of the Royal Society of Tropical Medicine & Hygiene 2007;101:621-23.