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Venous leg ulcers are the most common type of skin ulcer. They mainly occur just above the ankle. They usually affect older people and are more common in women. Other signs include varicose veins and haemosiderin staining above the ankles (brown pigmentation).


Intervention

Medical compression therapy applied externally to the lower leg to provide a constant pressure gradient (graduated compression), which improves venous return and reduces oedema.

The two most commonly used compression therapy systems are: compression bandages and compression hosiery. Compression systems may contain elastic or inelastic materials or a combination of both.

Indication

Improve healing of venous ulceration of the lower leg.

Leg ulceration is typically a chronic recurring condition with duration of episodes of ulceration ranging from weeks to more than 10 years. It can cause significant distress and cost.

The most common cause of lower extremity ulceration is chronic venous insufficiency due to calf muscle pump dysfunction. Compression therapy has two mechanisms of action: a static effect or resting pressure and a dynamic effect due to the changing circumference of the leg during walking.

Compression increases ulcer healing rates compared with no compression. The type of compression system also has an effect on healing rate: multicomponent systems are more effective than single component systems, and those with an elastic component are more effective than those with inelastic components. (See Availability and Description)

Contraindications

Compression should not be applied before appropriate assessment and exclusion of:

  • peripheral artery disease (e.g. ankle brachial pressure (ABPI) index <0.8)

and appropriate assessment and management of

  • cardiac, renal or liver failure
  • cellulitis
  • acute deep vein thrombosis (once anticoagulated).

Precautions

Trials investigating the effectiveness of compression therapy were generally conducted in populations without diabetes, cardiovascular disease, malignancy or mixed aetiology ulcers. Compression should be used with greater caution in these populations.

Compression therapy should only be used in patients who can detect increasing pain or complications and for whom the compression system can promptly be removed (by the patient or another person).

Adverse Effects

Most adverse effects associated with compression bandaging are avoidable (e.g. by not applying the bandage/s too tightly; placing additional padding over any bony deformities;

increased frequency of bandaging for exudative wounds);

and falls risk due to reduced agility.

Availability

Compression should be applied by a trained health professional and according to the manufacturer’s guidelines. Referral to a specialist chronic wound clinic may be appropriate, or if in rural or remote areas consider the use of teleconsultation to seek guidance

Compression bandages

Multiple compression bandages are available (see Table 1). They may be single component (i.e. one type of bandage) or multicomponent (i.e. two, three or four types of bandage, usually consisting of at least one absorbent component and at least one elastic component).

Note that use of the term ‘multicomponent’ rather than ‘multilayer’. There will always be some overlap when applying bandages, giving at least two layers of material at any point on the bandaged leg. Therefore, a bandage consisting of a single strip of fabric (single component) is not a single-layer system.

Examples of multicomponent bandage systems include:

  • short stretch/inelastic systems – orthopaedic padding plus one or two rolls of short-stretch bandages (SSB)
  • two-component bandage systems – orthopaedic padding plus elastic bandage
  • four-component bandage systems (commonly called four-layer bandage or 4LB) – orthopaedic padding plus support bandage (crepe) plus elastic bandage, plus elastic cohesive (outer) bandage.

The level of compression achieved during the placement of compression bandages is determined by the physical and elastomeric properties of the fabric, the size and shape of the limb, and the skill or technique of the clinician in providing the proper level of tension in the bandage fabric during its placement.

Walking is needed to achieve the full compressive effect of the bandage.

Compression hosiery (stockings)

Compression stockings are knitted garments made from various materials such as silk, cotton, polyester, nylon, natural rubber, polypropylene, or in combination. They may be panty style, above or below knee, made to measure or available in standard sizes. Compression stockings with zippers or Velcro fasteners are available and may be easier for patients to use (and increase compliance).

Compression stockings are available in a range of compression levels. International consensus on compression scales is lacking and different scales are used around the world. Patients purchasing compression garments from overseas on the Internet need to specify the compression level required for their condition. A classification of compression hosiery commonly used by Australian and New Zealand manufacturers is:

  • extra light (5 mmHg)
  • light (15 mmHg)
  • mild (18–24 mmHg)
  • moderate (20–40 mmHg)
  • strong (40–60 mmHg)
  • very strong (>60 mmHg)

Table 1. Compression therapy products available in Australia

Bandage category

Function

Compression

Types

Examples of brand names [NB1]

padding

protective layer under compression bandages

none

rolled wool

Soffban, Velband, SurePress Absorbent Padding

     

tubular

Samafrotte, Tubular plus

retention

hold dressings in place

often used for arterial ulcers

none

cotton crepe

Elastocrepe, Handycrepe, Telfa crepe. Should not be applied at full stretch as they will tornique if not full toe to knee coverage.

     

lightweight cohesive (stretch plus self-adhesion)

     

tubular (some compression, single or multiple layers, shaped or straight)

Tubifast, Tubular Conforming Band These are the most common products used as retention bandaging – appropriate size for the limb circumference required – manufacturer have sizing charts.

reduced compression

may be suitable for mixed venous and arterial ulcers when ABPI is between 0.6 and 0.8

18 to 24 mm Hg

heavyweight cohesive

Coban, Coplus, PEG, Handygrip, Flexwrap

     

tubular

Tubiform Straight, Handiplast Tubular, Tensogrip, Tubular Form

     

multicomponent systems

Profore Lite, Coban 2 Lite

high compression

used for venous ulcers when ABPI is between 0.8 and 1.2

25 to 35 mm Hg

tubular

Tubigrip Shaped, Tubular Form Shaped

     

multilayer straight tubular

Tubigrip Straight, Handiplast Tubular, Tensogrip, Tubular Form

     

short stretch (inelastic) bandage

Comprilan, Tensolan, Lastolan These bandages have a low (25-20mmHg) resting pressure and high (35 – 45mmHg0 active (walking or muscle contraction exercise) pressure.

     

long stretch (elastic) bandage

Setopress, Surepress, Tensopress

     

multicomponent systems

Profore, Proguide, Coban 2 layer. These have a high resting pressure (35 – 45mmHg) and a higher active pressure (50 – 60mmHg)

graduated compression stockings

used after venous ulcers have healed

18 to 24 mm Hg

 

Vairox, Fast Fit, Ultrasheer, Venosan 4001, Jobst

   

25 to 35 mm Hg

 

Health Support Hosiery, Varisma, Venosan 4002, Jobst 2 layer. These range for light compression (Class1 in Australia) to moderate compression (Class2 – the most commonly used) to high compression (Class 3 – large legs or multiple recurrences)

NB1: This is not a complete list, but represents a selection of products available in Australia at the time of publication.

ABPI = ankle brachial pressure index

Source: Therapeutic Guidelines. Wound Therapies: compression <<link to http://online.tg.org.au/complete/desktop/index.htm>> Accessed 25 November 2015.

A pilot study (2010) found that, on average, patients spent $114 a month managing their ulcer. The majority (about 61%) of cost was associated with primary dressings. Secondary dressings and fees for health services each accounted for about 13% of patient expenses. The balance of costs to the patient was for transport, medication and other expenses. Heavily exudating ulcers were more costly to manage than those with light exudate.

Description

Selection of compression system

According to the Australian and New Zealand Clinical Practice Guideline for the Prevention and Management of Venous Leg Ulcers, the choice of a compression system should be made in consideration of:

  • shape and size of the leg
  • patient tolerance and preference
  • clinician experience in application
  • the environment (e.g. temperature)
  • ease of application and removal
  • access to services
  • presence of other disease
  • level of activity/weight bearing
  • cost

When compression bandages are chosen, a multicomponent compression system with an elastic component is recommended.

Application of compression bandages

All types of compression bandages should be applied from the base of the toe to the knee (or proximal calf). They can be applied in spiral or figure of eight patterns (as per the manufacturer's instructions). Care should be taken to avoid excessive compression of skin against any bony prominences. Use an extra layer of padding bandage or soft foam or folded combine pad to flatten area around bony prominences. The leg may be padded out in appropriate areas to ensure a standard smooth curved leg shape with the ankle circumference half of the calf circumference. (See videos in Training)

Application of compression stockings

Proper measurement and fitting of the stockings, specific patient instruction, and encouragement may enhance compliance with compression stockings. Wash new compression stockings by hand before wearing to reduce some of the initial stiffness and difficulty in application.

Stockings should be put on in the morning when oedema is minimal and after the placement of ulcer dressings, if any. If there will be a delay after rising from bed (e.g. shower), it is useful to elevate the legs by lying as flat as possible in bed (not a reclining chair)for 20–30 minutes prior to putting on the stockings.

Tips and Challenges

Effective treatment of chronic venous leg ulcers is time consuming and depends on appropriate assessment, which includes examination of the ulcer and the patient. (See Training) Patient education and a positive therapeutic relationship are also necessary for effective treatment.

Noncompliance with compression therapy is common; estimated in around 60–70%. Factors contributing to low compliance include discomfort, itching, tightness, difficulty with application, pins and needles sensation and rash. Additionally, patient beliefs that compression therapy is unnecessary and ineffective are significantly related to nonadherence.

A simple device, referred to as a stocking aid (or butler or donner), is helpful for patients with limited strength or hand mobility or patients who have difficulty bending over (e.g. obesity, spine problems). Higher grade compression stockings may go on more easily if a light .liner sleeve is worn (eg Jobst Ulcer Care Compression Liners or a single layer of Tubifast retention bandage) is worn under the compression garment.

Compression stockings absorb skin oils and cause the skin to dry out so the skin should be moisturised in the evening (with a mild keratolytic emollient preparation such as Nutraplus or Calmurid) just prior to reclining in bed after the stockings are removed.

Patients with access to the RPBS (http://www.pbs.gov.au/browse/rpbs) can have these bandages provided to them via an RPBS prescription.

Training

For a complete explanation and recommendations regarding assessment and comprehensive management of venous leg ulcers see Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers.

Additional information about assessment and management of venous leg ulcers is available from:

Sankar S, Sadhishaan S. Management of venous leg ulcers in general practice – a practical guideline. Australian Family Physician. 2014;43(9):594-8. <<http://www.racgp.org.au/afp/2014/september/management-of-venous-leg-ulcers-in-general-practice-–-a-practical-guideline/>>

Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum. <<link to http://www.jvascsurg.org/article/S0741-5214%2814%2900851-9/fulltext#sec8>>

Principles of compression in venous disease: a practitioner’s guide to treatment and prevention of venous leg ulcers. Wounds International, 2013. <<link to http://www.woundsinternational.com/media/issues/672/files/content_10802.pdf>>

Scottish Intercollegiate Guideline Network (SIGN) Guideline 120: Management of chronic venous leg ulcers summary of recommendations. <<link to http://www.sign.ac.uk/guidelines/fulltext/120/recommendations.html>>

Videos showing placement of bandages:

Application of a 2 component bandage system <https://youtu.be/FqKjBE6_0AU>

Application of a 4 component bandage system < https://youtu.be/l0iuNjZ0SmQ>

Grading

NHMRC level I

References

O'Meara S, Cullum N, Nelson EA, Dumville JC. Compression for venous leg ulcers. Cochrane Database Syst Rev. 2012;11:CD000265.

Smith, E and McGuiness, W. Managing Venous Leg Ulcers in the Community: Personal Financial Cost to Sufferers. Wound Practice & Research: Journal of the Australian Wound Management Association. 2010;18(3): 134-139.

Consumer Resources

The Australian Wound Management Association (AWMA) has produced handouts for patients with venous leg ulcers. http://www.awma.com.au/publications/

Acknowledgments

The RACGP gratefully acknowledge the contribution of Dr Dianne Smith, Senior Medical Officer at the Wound Clinic, Royal Brisbane and Women's Hospital, in the development of this intervention.  

First published: January February 2017

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