Cutaneous Clues to Lymphatic Disease: Bedside Recognition of Lymphedema, Lymphatic Malformations, and Mimics

Lymphatic disorders encompass a diverse group of congenital and acquired conditions that often first manifest in the skin. Edema, vesicles, verrucous change, erythema, and vascular-appearing lesions overlap with common venous, infectious, neoplastic, and systemic disorders, which makes recognition of lymphatic disease challenging and contributes to diagnostic delay. This review examines the cutaneous manifestations of lymphedema and lymphatic malformations with an emphasis on bedside diagnosis, common mimics, and clinically important pitfalls. We first discuss the clinical evolution of lymphedema and features that distinguish primary from secondary disease, including infectious and oncologic causes and complications. We then review superficial and deep lymphatic malformations, acquired lymphangiectasia, and syndromic disorders including PIK3CA-related overgrowth spectrum and complex lymphatic anomalies. Throughout, we highlight practical clues that can guide imaging, biopsy, genetic evaluation, and multidisciplinary referral.