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Page 4 of 10 Wiedner et al. Plast Aesthet Res 2020;7:10 I http://dx.doi.org/10.20517/2347-9264.2019.51

Figure 3. Different stages of lipedema according to the size of the fat nodules in the subcutaneous tissue: (left) Stage 1 shows a thickening
of the subcutaneous tissue with small palpable nodules; (middle) Stage 2 already shows bigger fatty nodules up to walnut-size; and (right)
Stage 3 is defined by overhanging skin-fat lobules, especially in the medial knee area or the development of severe column legs with cuff
sign

One such is benign lipohypertrophy. Morphologically, lipohypertrophy may resemble lipedema. Women
suffer from a constitutional disproportion of body shape with symmetrical hip- and thigh-obesity. The most
common form of lipohypertrophy is the “riding breeches” obesity. The upper extremities are rarely affected.
[19]
In contrast to lipedema, lipohypertrophy presents without pain, edema, or bruising . It is thought that
lipedema may develop from lipohypertrophy over time [20,21] . However, it is not entirely clear that these are
truly separate conditions.

Another differential diagnosis of lipedema is primary lymphedema, which may also affect women around
puberty. Concerning differences between lipedema and primary lymphedema, patients with lipedema
present symmetrical swellings, whereas primary lymphedema is usually asymmetrical [Figure 4]. While
lymphedema typically starts at the toes and subsequently reaches the thighs, swellings in lipedema patients
usually affect the thighs first. One clinical differentiating factor is the Stemmer sign: lymphedema often
presents a positive Stemmer sign, which describes the inability to pinch the skin over the proximal phalanx
[22]
of the second toe, while Stemmer sign is negative in pure lipedema [Figure 5]. Another significant
difference between lipedema and lymphedema is the presence of pain and frequent bruising in lipedema.
[10]
However, a visible lymphedema can occur with any stage of lipedema .
Phlebolymphedema is the result of chronic venous insufficiency. It may occur in men and women, either
uni- or bilaterally. Discolorations of the skin, varicose veins, or ulcer formations are typical symptoms. In
contrast to lipedema, ultrasound examination in phlebolymphedema shows pathological findings. However,
women with lipedema may also have varicose veins and may develop phlebolymphedema as a result of
[20]
these .

Dercum’s disease, also known as adipositas dolorosa, describes a condition characterized by generalized
obesity and painful, fatty tumors (lipomata) in the adipose tissue, occurring almost exclusively in women.
The tumors are found on the extremities, without involvement of the feet. It is said that it commonly
develops around menopause. In contrast to lipedema, edema is not present. Muscular weakness and fatigue,
[23]
emotional instability, depression, and alcohol abuse are potential features of the disease . However, it is
controversial whether Dercum’s disease represents a separate entity or it is only a variant of lipedema.