Abstract
To the editor,
With great interest we read the recent article titled “A multidimensional evaluation of pain in lipedema” by Sakızlı Erdal et al., published in Phlebology. 1 Pain is one of the most prominent symptoms of lipedema and represents a major factor affecting patients’ quality of life. Therefore, studies aimed at improving the understanding of pain mechanisms in lipedema are of considerable clinical importance. We would like to commend the authors for addressing such an important and clinically relevant topic.
Nevertheless, we believe that several methodological aspects of the study may warrant further discussion.
First, the absence of a control group in the study makes it difficult to interpret the reported high prevalence of central sensitization (83.5%). Although the Central Sensitization Inventory (CSI) is widely used as a screening tool in chronic pain research, elevated CSI scores are known to occur across a variety of chronic pain conditions.2,3 Therefore, without the inclusion of a control group, it becomes challenging to determine whether the reported prevalence is specific to lipedema or reflects a broader feature of chronic pain populations.
In the study, hypersensitivity was assessed using a verbal rating scale ranging from 0 to 3. While this approach may be practical in clinical settings, it remains limited when compared with objective sensory assessment methods commonly employed in chronic pain research. The use of quantitative sensory testing and other objective measurement techniques has been recommended in the evaluation of central sensitization, as these approaches may provide a more reliable and reproducible assessment of pain sensitivity. 4 Consequently, relying solely on patient-reported measures may restrict the interpretation of hypersensitivity findings.
In the study, anthropometric assessment was based solely on body mass index (BMI). However, recent literature suggests that BMI alone may not be sufficient to adequately characterize fat distribution in lipedema. Parameters such as waist circumference or waist-to-height ratio have been emphasized as potentially providing additional information, particularly in distinguishing lipedema-related adipose tissue distribution from central obesity. 5
The study references the Wold–Herbst criteria as the basis for the diagnosis of lipedema in the inclusion criteria. However, providing a clearer description of the specific clinical parameters used for patient selection, as well as the conditions considered as exclusion criteria, would have facilitated a more comprehensive understanding and interpretation of the study population. In addition, pain in patients with lipedema is known to have a multifactorial and heterogeneous pathophysiology. 6 In this context, the inclusion of patients with a diagnosis of chronic venous disease (as shown in Table 1) may represent a potential confounding factor when interpreting pain-related outcomes. Furthermore, it is not clearly specified whether patients receiving treatment for neuropathic pain due to chronic pain syndromes or other conditions were excluded from the study. Such factors may also influence pain-related assessments. 4 Therefore, a more detailed definition and control of these variables within the study design could strengthen the interpretation of the reported findings.
Despite these limitations, the study makes a valuable contribution by drawing attention to the multidimensional nature of pain in lipedema. Future research incorporating control groups, objective sensory testing methods, and a more detailed evaluation of potential confounding factors may help to further clarify pain mechanisms in lipedema and improve our understanding of the potential role of central sensitization in this condition.
