Compression therapy for venous leg ulcers

The purpose of compression therapy when managing venous leg ulcers is to promote wound healing and minimise the risk of recurrence.

A venous leg ulcer is ‘a break in the skin below the knee, which has not healed within 2 weeks’ and occurs when a person has a venous disease (National Institute for Health and Care Excellence (NICE), 2023a). Venous leg ulcers commonly recur, so people with this condition often present to healthcare services multiple times (Probst et al, 2021).

Compression therapy

Compression therapy is the gold standard for the management of a patient with a venous leg ulcer. This involves the application of controlled external pressure on a patient’s leg to improve venous blood flow back to their heart and minimise the effects of venous hypertension in the circulatory system (Wounds UK, 2022).

Compression can be applied with multilayer compression bandages or systems (four and two layers, respectively), compression wraps and/or compression hosiery. Once commenced, compression therapy is usually used indefinitely to reduce instances of recurrence (post healing or prophylactically) (NICE, 2023b).

Compression therapy aims to reverse the effects of venous hypertension by:

• decreasing the capacity and pressure in the superficial veins, aiding venous return by increasing blood flow velocity in the deeper veins
• reducing oedema by decreasing the osmotic pressure difference between capillaries and the surrounding tissue, facilitating the transfer of fluid back into the vascular space
• minimising or reversing skin changes or ulceration to aid healing, in combination with the use of appropriate modern interactive wound dressings (Collier, 2023)

A recent systematic review about the use of compression therapy for the management of venous leg ulcers reported that, in the majority of included papers:

It is generally agreed that ‘some compression is better than no compression’ and that compression therapy should be used for the management of all patients with a venous leg ulcer, if there are no contraindications, from the first visit or earliest opportunity (Wounds UK, 2022; European Wound Management Association (EWMA), 2023a; 2023b).

Before any compression device (such as a bandage, wrap, hosiery, intermittent pneumatic compression system) is applied – either for prophylactic, maintenance or management reasons – a holistic assessment of the patient should be undertaken and fully documented. This should include a comprehensive assessment of the patient’s lower limb and peripheral circulation if the patient has undiagnosed disease, diabetes or a wound on the lower limb (National Wound Care Strategy Programme (NWCSP), 2023).

The comprehensive assessment should consider:

• all physical and psychological needs
• any current medical conditions
• a review of medication, pain and analgesia needs
• the presence or absence of clinical signs of infection
• current nutritional intake and needs

Assessment of the patient’s lower limb should include consideration of:

• skin condition, tone and the presence or absence of a lower limb wound
• limb length, size, shape (eg an inverted champagne bottle shape – the lower limb is noticeably wider just below the knee than around the malleolus) and muscle tone (any noted or reported reduction or loss of calf muscle)
• limb temperature
• general mobility and ankle movement
• the presence or absence of erythema, pallor and/or cyanosis
• signs of venous insufficiency (eg oedema, ankle flare, hyperpigmentation, lipodermatosclerosis, atrophie blanche, varicose eczema)
• the presence or absence and distribution of any lower limb oedema
• overall hygiene and skin care, presence of hyperkeratosis, fungal infection
• vascular assessment (eg Doppler or venous duplex scanning)
• a neuropathic assessment if the patient has diagnosed diabetes or a lower limb circulatory condition (Wounds UK, 2022; NWCSP, 2023; NICE, 2023a).

Vascular assessment of a patient’s peripheral circulation can be undertaken using a hand-held Doppler device (Benbow, 2011). The highest ankle and brachial pressure recordings documented during the assessment are used to calculate the patient’s ankle brachial pressure index (ankle systolic pressure/brachial systolic pressure), which will help indicate their suitability for compression therapy (Table 1).

When undertaking a vascular assessment, such as with a hand-held Doppler device, it is important to note that the resultant ankle brachial pressure index does not diagnose venous disease, but rather excludes significant arterial disease. This indicates that it is safe to consider the use of compression therapy and/or a compression device on the patient’s relevant lower limb (Wounds UK, 2022).

However, despite the fact that a Doppler assessment is accepted as a fundamental step of the assessment process, it has been estimated that only 15% of all patients with a leg or foot ulcer in the UK had a Doppler ankle brachial pressure index recorded in their notes (Guest et al, 2020).

If the patient has confirmed diabetes or peripheral arterial disease, or their experience of previous ankle brachial pressure index assessments was too painful, then the brachial pressure can be assessed in the toe instead (Patry et al, 2022).

In patients with a longstanding venous leg ulcer or multiple comorbidities, the vascular assessment may be undertaken in a vascular assessment unit. This will require referral to a vascular surgeon.

NICE (2023a) have recommended that all patients wearing any form of compression therapy should have a regular arterial re-assessment to ensure that their arterial status has not deteriorated. Subsequent reassessments are usually scheduled based on the patient’s cardiovascular risk profile, for example, every 12 months for patients with a venous leg ulcer and either quarterly or twice yearly for patients with mixed ulcers (recorded vascular and arterial changes). Nevertheless, re-assessments should be completed sooner if clinically indicated, such as if there are any concerns that deterioration of the patient’s venous leg ulcer is because of a change in their vascular status, or they report a change in symptoms (eg night or rest pain).

Compression therapy systems may contain elastic (capable or stretching) or inelastic (minimal extensibility) bandages or a combination of both – refer to the manufacturer’s information (Ousey et al, 2021).

Bandage systems and compression hosiery are classified according to the level of compression they generate. Several classification systems exist (eg British or European). WUWHS (2008) suggested the following terminology when describing the level of compression to be applied to a limb:

• mild (less than 20 mmHg)
• moderate (20–40 mmHg)
• strong (40–60 mmHg)
• very strong (>60 mmHg)

Strong compression (>40 mmHg) is generally recommended for the treatment of a venous leg ulcer. However, for some patients, clinical factors such as arterial disease, neuropathy or cardiac failure mean that strong compression may be unsafe or painful, so the use of mild or moderate compression may be indicated (eg inelastic compression). Patients with severe arterial disease (ankle brachial pressure index <0.5) should not have compression applied.

1. Undertake a holistic patient and skin assessment within 14 days of new or recurring lower-limb ulcer presentation (NWCSP, 2023) – record past medical history, note if the patient is allergic to any creams, wound or bandage materials.
2. Undertake a full leg ulcer assessment – record fully in local wound assessment documentation.
3. Undertake a comprehensive limb and vascular assessment as clinically indicated.
4. Refer to a vascular specialist for further assessment (eg in a vascular lab) and ongoing management, if clinically indicated.
5. Apply clinically indicated skin creams and/or emollients to the patient’s affected leg. Refer to the manufacturer’s instructions for application before use.
6. Apply an appropriate modern interactive wound dressing and/or product to venous leg ulcers and/or associated skin breaks present on the patient’s lower limb, as clinically indicated. Refer to the manufacturer’s instructions prior to the use of any chosen wound dressing product.
7. Apply compression therapy as clinically indicated. Refer to the manufacturer’s instructions before use of the chosen bandage, wrap or hosiery system as appropriate for the stage of management.
8. Agree a reassessment date with the patient.

Refer to local or national guidelines for the management of a patient with a venous leg ulcer and/or the use of compression therapy. Involve the patient at all stages of the assessment and management process. Refer to all manufacturers’ instructions as appropriate. The nurse may refer the patient to an appropriate specialist, clinic or suitable qualified colleague if they feel unable to manage the patient or are unconfident or untrained to apply compression.

See here for an example of a checklist for the assessment of a patient with a leg ulcer.

A failure to recognise the presence of arterial disease during the assessment process will result in the unsafe application of high compression therapy.

A failure to apply the correct level of compression may lead to deterioration of venous leg ulcers, increased patient pain experiences, delayed wound healing and negative effects on the patients’ health-related quality of life.

Nurses can use the information outlined in this article to evaluate policies for the use of compression therapy in patients with a venous leg ulcer in their healthcare setting – is it evidence-based? Is it up to date? If a policy is not established, nurses should consider speaking to their manager and colleagues about the need for prompt development of a policy for the assessment of a patient with a venous leg ulcer and the use of compression therapy during management.

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages

Part 2: Procedures for the planning, provision and management of person-centred nursing care

4. Use evidence-based, best practice approaches for meeting the needs for care and support with hygiene and the maintenance of skin integrity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

7. Use evidence-based, best practice approaches for meeting needs for care and support with mobility and safety, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions.

EWMA compression programme

WUWHS

NHS: Venous leg ulcers

Wounds UK: Venous leg

Legs Matter

References

Benbow M. A guide to Doppler ultrasound assessment. 2011. https://www.nursinginpractice.com/clinical/wound-care/a-guide-to-doppler-ultrasound-assessment/ (accessed 27 September 2023)

Collier M. Wound Dressings: an introduction. 2023. https://www.bjninform.com/clinical-a-z/wound-dressings-an-introduction/ (accessed 27 September 2023)

European Wound Management Association (EWMA). Compression therapy programme 2023a. https://ewma.org/whatwe-do/projects/lower-leg-ulcer-diagnosis-treatment (accessed 27 September 2023)

European Wound Management Association (EWMA). Compression therapy knowledge centre. 2023b. https://ewma.org/what-we-do/compression-therapy (accessed 27 September 2023)

Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK's National Health Service in 2017/2018: update from 2012/2013. BMJ Open. 2020;10(12):e045253. https://doi.org/10.1136/bmjopen-2020-045253

Isoherranen K, Montero EC, Atkin L et al. Lower leg ulcer diagnosis & principles of treatment. J Wound Management, 2023;24(2 Sup1):s1-76. https://doi.org/10.35279/jowm2023.24.02.sup01

National Institute for Health and Care Excellence (NICE). Scenario: venous leg ulcers. 2023b. https://cks.nice.org.uk/topics/leg-ulcer-venous/management/venous-leg-ulcers/ (accessed 27 September 2023)

National Institute for Health and Care Excellence (NICE). Leg ulcer – venous. 2023a.  https://cks.nice.org.uk/topics/leg-ulcer-venous/ (accessed 27 September 2023)

National Wound Care Strategy Programme (NWCSP). Leg and foot ulcers. 2023. https://www.nationalwoundcarestrategy.net/lower-limb/ (accessed 27 September 2023)

Ousey K, Atkin L, Conway B et al. Compression therapy for pharmacy teams. London: Wounds UK; 2021

Patry J, Laurencelle L, Bélisle J, Beaumier M. Vascular assessment in patients with a lower limb wound: a correlational study of photoplethysmography and laser doppler flowmetry toe pressure techniques. J Diabetes Sci Technol. 2022;16(2):470-477. https://doi.org/10.1177/1932296820979973   

Probst S, Weller CD, Bobbink P, et al. Prevalence and incidence of venous leg ulcers-a protocol for a systematic review. Syst Rev. 2021;10(1):148. https://doi.org/10.1186/s13643-021-01697-3   

World Union of Wound Healing Societies (WUWHS). Principles of best practice: compression in venous leg ulcers. London: MEP Ltd; 2008

Wounds UK. Best practice statement: holistic management of venous leg ulceration (second edition). 2022. https://wounds-uk.com/best-practice-statements/holistic-management-venous-leg-ulceration-second-edition/ (accessed 27 September 2023)