Compression for venous leg ulcers

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)

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

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

Appropriate assessment and management of:

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

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).

Most adverse effects associated with compression bandaging are avoidable (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.

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 (one type of bandage) or multicomponent (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

Source: Therapeutic Guidelines. Wound Therapies: compression 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.

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.

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 can have these bandages provided to them via an RPBS prescription.

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.

Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery® and the American Venous Forum.

Principles of compression in venous disease: a practitioner’s guide to treatment and prevention of venous leg ulcers. Wounds International, 2013.

Scottish Intercollegiate Guideline Network (SIGN) Guideline 120: Management of chronic venous leg ulcers summary of recommendations.

Videos showing placement of bandages:

Application of a 2 component bandage system

Application of a 4 component bandage system

NHMRC level I

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.