Introduction

Elephantiasis is a chronic condition characterised by unusual swelling of the affected limb due to the accumulation of excessive lymphatic fluid in the lymph vessels, a condition known as lymphoedema.^1,2 

This buildup occurs because of an infection caused by parasitic worms, which is why the condition is also referred to as lymphatic filariasis.^3,4 The fluid collects slowly over many years in the body's tissues, making elephantiasis a long-term or chronic condition. 

The lymphatic system is a network of vessels designed for removing waste products, maintaining fluid balance, and fighting infections. When these lymph vessels become blocked, the normal flow of lymph is disrupted. This can lead to noticeable changes such as swelling, thickening, and hardening of the affected limb.¹ 

Elephantiasis primarily affects the upper and lower limbs, especially your legs, causing severe swelling. Additionally, it can involve the genital area in males and the chest or breast region in females, due to the unusual growth of the skin and the tissue beneath it.^2,5,6

The World Health Organisation (WHO) reports that about 51 million people are affected globally, with nearly 36 million living with long-term symptoms such as lymphoedema (swelling) and hydrocele (scrotal swelling).⁶

Lymphatic filariasis (LF), a neglected tropical disease, arises from infection by parasitic worms that spread to humans through mosquito bites.^5,6,7 Despite not being deadly, LF causes serious problems and great suffering to the affected individuals. In addition to the visible changes seen in the figure, it also affects people’s mental health, social life, and financial well-being. LF reduces mobility and makes it difficult to work or carry out daily activities, often causing poverty and hardship.⁵ A lack of awareness and misunderstanding about the disease results in inadequate access to care. The World Health Organisation (WHO) reports that about 51 million people are affected globally, with nearly 36 million living with lasting symptoms such as lymphoedema (swelling) and hydrocele (scrotal swelling).⁶

Causes

Elephantiasis results from both filarial (parasitic) and non-filarial causes. 

Filarial elephantiasis 

Filarial worms are a large group of thread-like parasites and are the most common cause of elephantiasis. Many people from tropical regions – warm, humid areas where healthcare facilities are limited – experience this condition.² The parasitic worms responsible for causing elephantiasis include Wuchereria bancrofti (responsible for about 90% of cases all around the world), Brugia malayi, and Brugia timori.^1,5,6,8

More than 70 types of mosquitoes carry Wuchereria bancrofti to humans.⁵ Once inside the human body, the worms mature and reside in the lymphatic vessels or nearby lymph nodes. Within these vessels and nodes, they disrupt normal lymphatic function and block fluid drainage, causing swelling and changes in the underlying tissue of the affected body part.^1,9

Non-filarial causes of elephantiasis

While Filaria worms are the leading cause, elephantiasis can also result from non-parasitic conditions. The second most common type is Elephantiasis nostras (ENV), blockage of lymphatic vessels due to non-infectious causes, leading to significant skin changes.^1,5 Other possible non-filarial causes of elephantiasis include:

• Systemic condition: ‘venous insufficiency’ means that vessels in the legs have trouble moving blood back to the heart, which can also contribute to lymphoedema² 
• Recurrent infections: frequent bacterial infections (e.g., erysipelas, cellulitis), streptococcal infections, tuberculosis, leprosy, leishmaniasis, and sexually transmitted infections such as lymphogranuloma venereum^1,5 
• Congenital malformations (birth defects): single limb involvement (unilateral elephantiasis) with early onset may suggest birth defects of the lymphatic system or inherited conditions, in the absence of infection or injury¹
• Irritating soil particles: found in volcanic soils, often cause elephantiasis⁵
• Other possible triggers: increased body weight (obesity), trauma or injury and previous surgical procedure or radiotherapy¹

Although elephantiasis is a long-term condition, understanding its possible complications, such as infections and skin changes, can help you take steps to prevent them.

Complications: secondary infections and ulcerations

The long-term swelling seen in elephantiasis weakens the body’s natural defences, increasing the risk of secondary infections and other skin complications, including ulceration. 

Risks of secondary infections

The initial step in the development of elephantiasis is the blockage of lymphatic vessels over a long period of time, leading to the accumulation of thick, protein-rich fluid in the affected tissues, causing persistent swelling or lymphoedema. Due to the impaired lymphatic drainage system, the movement of immune cells, pathogens, and large molecules is slowed.⁶ The ongoing inflammation and repeated skin infections create typical changes in the affected limb, such as a thickened, rough, or warty appearance of skin. These changes, along with lymphoedema, destroy the skin’s protective barrier through cracks, ulcers (open sores), and impaired defences, which can result in complicated infections like cellulitis in the affected limb.

Cellulitis and erysipelas are the most common bacterial infections that occur in the severity of elephantiasis. These infections are linked with continuous inflammation in the lymph vessels, worsening the lymphoedema and creating an unstoppable cycle, where swelling leads to infection, and infection makes the swelling worse.^2,10 This is a dangerous pattern, especially in people with chronic health conditions like diabetes, where wound healing is slower and protective responses are weaker.² In some cases, bacterial infections can result in critical conditions that may require intensive care in the hospital, such as sepsis, which is commonly found in people with elephantiasis nostras verrucosa (ENV), a rare yet extreme form of non-filarial elephantiasis.¹¹ 

Other bacteria, including Pseudomonas aeruginosa, have also been identified. They also have well-known complications, especially in people with elephantiasis, which can also increase the risk of bacterial infection. The affected area may become thick, warty (rough), and hard, often forming extra folds, especially in people with complicated elephantiasis. As the condition worsens, along with the development of cracks and open sores (ulcers), gangrene (death of body tissue) becomes noticeable in the affected body part.¹³ In addition to these changes, crusts and moisture between the toes create entry points for bacteria and fungi, leading to unusual changes in the involved limbs, such as thickening, hardening, small wart-like growths, and bumpy, uneven skin, because of repeated inflammation.²

Preventive skin care interventions in elephantiasis

Proper management of elephantiasis depends on skin and wound care to reduce swelling, prevent infections, and improve lymphatic flow.

Oedema reduction and compression therapy

• Compression therapy has a key role in controlling swelling. treatment option to control swelling with the use of bandages, compression stockings, and multi-layer inelastic wraps.^1,2,10 Daily use of pneumatic compression devices on the legs under supervision can also help manage lymphoedema¹⁰
• Manual lymphatic drainage (a gentle massage technique that helps move excess fluid (lymph) from swollen tissues towards healthy lymphatic vessels for drainage), along with physical therapies such as pressotherapy, uses controlled air pressure to stimulate drainage, improving lymphatic function¹
• Elevating the affected leg is also recommended to help reduce swelling¹²

Topical treatments (medications applied to the skin)

Healthcare providers may recommend the following treatments to care for the skin and prevent infections:

• Retinoid creams can help soften thickened skin and reduce small wart-like growths¹⁰
• Urea or 10% salicylic acid treatments also improve the texture and the hardness of the skin^2,10
• Emollient creams or lotions should be gently massaged over the entire affected area to keep the skin hydrated and healthy²
• Mupirocin ointment can be applied to sores and wounds caused by bacterial infections, with a doctor’s prescription²
• Antifungal creams, such as terbinafine, are advised by the physicians to treat fungal infections, especially between the toes²

Wound management and debridement

• Sterile dressing every day is a must to keep wounds clean and prevent infection¹²
• Surgical debridement can be done to get rid of thick, warty, or rough skin^1,10
• Dermabrasion, a procedure that gently removes thickened skin layers, may be used when necessary in certain conditions, like ENV, to improve skin texture. However, it is important to note that this procedure can sometimes cause increased swelling as a side effect¹⁰
• Negative-pressure wound therapy (NPWT) uses a vacuum pump to heal infected wounds, control bleeding and support wound closure. It can also be effective when the skin breaks down due to ulcers or when skin grafts are needed¹⁴
• Platelet-rich plasma (PRP) injections are also beneficial in wound healing and promoting faster recovery¹²

Systemic treatments

• Antibiotics, when advised by a physician, can be used for treating bacterial infections like cellulitis^2,11
• Antifungal medications such as oral fluconazole are the treatment of choice for fungal infections²
• Antiparasitic medications like diethylcarbamazine (DEC) or ivermectin, sometimes combined with doxycycline, are prescribed for people with filarial elephantiasis to kill the adult worms¹
• Coumarin (a vascular-protective agent) can help reduce swelling and other symptoms of elephantiasis by enhancing immune cell activity, removing excess protein, and controlling long-term tissue damage¹²

Self-medication without a doctor’s prescription can cause harm, so these medications should only be taken under medical guidance.

Skin health and protection

Incorporating appropriate skincare practices into daily life is essential to prevent the entry of bacteria and fungi and to protect overall skin health.^2,8

Addressing emotional and social challenges

Dealing with stigma and isolation

The word ‘elephantiasis’ is derived from its resemblance to an elephant’s leg and hence carries a bad reputation or stigma. Healthcare providers would rather not use the term in order to lessen the stigma attached to it.⁸ Excessive swelling and noticeable body changes may cause social stigma, making people feel embarrassed and withdraw from social activities with the intent of hiding their condition.^3,8 Community-wide education helps reduce shame and embarrassment, encouraging individuals to accept treatment and participate in prevention.⁸

Improving mental health and quality of life

In addition to physical disability, people with elephantiasis frequently experience mental health problems, particularly anxiety and depression. Neglected tropical disease programmes efficiently provide mental health support to those in need. It is necessary to take steps towards reducing the stigma associated with the term ‘elephantiasis’ as it helps in managing depression and improving the overall quality of life.⁸

Patient-centred care

Lymphoedema counselling helps healthcare providers understand the real-life challenges faced by patients, forming the basis for complete care. This approach also promotes social interaction through targeted group discussions during active treatment stages.³ 

Odour management

An unpleasant smell can limit social interactions and impact daily life at home. The odour may be especially noticeable in crowded treatment rooms. Ayurvedic herbal soaks and oil massages may help reduce both body odour and room smells.³

Home health aide

In order to prevent the condition from getting worse, having a home health aide or regular caregiver can be encouraged to follow the treatment regimen as instructed.¹⁵ The ultimate responsibility lies in the hands of those affected. For instance, if somebody who has developed elephantiasis sticks to a daily routine involving skin care and other recommended practices and has supportive people around them, then significant improvements can be observed in their condition.³ 

Summary

Elephantiasis occurs due to long-term accumulation of fluid in the lymphatic vessels, leading to massive swelling and hardening of limbs, mainly legs. This condition is mostly caused by a parasitic infection, resulting in impaired lymphatic drainage. When the lymphatic system gets blocked, fluid accumulates in the tissues, resulting in swelling and thickening of the affected limb. Damage to the skin barrier, due to long-term swelling and inflammation, allows the entry of tiny organisms like bacteria and fungi. The resulting infection by these organisms further weakens the immune response and creates an ongoing cycle where lymphoedema leads to infection, which can worsen lymphoedema. 

Every day, proper skin and wound care, such as maintaining hygiene, washing the affected area with mild soap, and moisturising the skin, is crucial for maintaining skin health. The challenges that come with elephantiasis extend beyond physical disability; therefore, management requires a complete patient-centred approach that includes wound care, mental health support, stigma reduction, and ongoing medical supervision. Long-term management and prevention of complications is only possible with strict adherence to medical treatment, daily self-care practices, and mental health support through social interaction and participation in community programmes.