The authors define the positive Stemmer sign in this way: “the skin fold between the second and third toe is thickened and cannot be lifted.” (1) This requires some additional explanation.
In 1976 Robert Stemmer described a clinical sign for the early and differential diagnosis of lymphedema. Lymphedema can be determined by means of a thickened longitudinal fold when pinching the skin of the upper side of the proximal phalanx of the second or third toe (2). The Stemmer sign is considered proof of lymphedema, but its absence does not rule out lymphedema. Usually, three severity grades are differentiated in the Stemmer sign (3, 4): barely pronounced (stage I) equals a skin fold width of 0.5–1 cm, moderately pronounced (stage II) equals >1 cm, and severely pronounced (stage III) means the skin fold cannot be lifted at all. A thickening of the retromalleolar region and/or evened or ballooning dorsal surface are similarly common in lymphedema and specific, like the Stemmer sign (3). Pathophysiologically, these symptoms are caused by lymphostatic fibrosis.
A Stemmer sign in stage III lipedema does not confirm lipedema but lipo-lymphedema.
References
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