What is the most effective technique for applying compression stockings to manage venous (varicose vein) ulcers?

From the Guidelines

For venous ulcer treatment, graduated compression stockings with a pressure of 30-40 mmHg at the ankle are the most effective technique, as they have been shown to improve venous return, reduce edema, and promote wound healing 1.

Key Considerations

• The compression should be graduated, with higher pressure at the ankle and decreasing pressure up the leg, to facilitate venous return and reduce venous hypertension.
• Patients should wear the stockings daily during waking hours and replace them every 3-6 months as they lose elasticity over time.
• Before starting compression therapy, an ankle-brachial index (ABI) should be performed to rule out arterial disease, as compression is contraindicated in patients with significant arterial insufficiency (ABI <0.5) 1.
• For patients who cannot tolerate or apply high-compression stockings, alternatives include multi-layer compression bandaging systems, Unna boots, or lower-compression stockings (15-20 mmHg) combined with leg elevation.

Proper Sizing and Application

• Proper sizing is crucial for effectiveness and comfort; measurements should be taken early in the morning when leg swelling is minimal.
• The stockings should be applied in the morning before getting out of bed when leg swelling is minimal.

Evidence-Based Recommendations

• The use of graduated compression stockings has been supported by multiple studies, including those published in the Journal of the American College of Radiology 1.
• The American College of Physicians recommends against the use of mechanical prophylaxis with graduated compression stockings for prevention of venous thromboembolism in hospitalized patients, but this does not apply to the treatment of venous ulcers 1.
• The effectiveness of compression therapy stems from its ability to counteract the increased hydrostatic pressure in the venous system that leads to edema, inflammation, and ultimately tissue breakdown in venous disease 1.

From the Research

Techniques for Venous Ulcer Compression Stockings

• The most effective technique for venous ulcer compression stockings is a topic of ongoing research, with various studies comparing the efficacy of different methods 2, 3, 4, 5, 6.
• Compression therapy is considered a crucial conservative treatment for venous leg ulcers, with medical compression stockings being the first choice of treatment 2.
• Multicomponent compression systems are more effective than single-component compression systems, and high compression is more effective than lower compression 2.
• Medical compression stockings are more effective than compression with short stretch bandages in preventing recurrent ulcers 2.

Comparison of Compression Bandages and Stockings

• A study comparing high-pressure compression stockings and compression bandages for ulcer treatment in venous ulcer patients found that compression bandages may be more effective in reducing ulcer size, calf circumference, and pain 5.
• However, another study found that compression bandages or stockings probably have a shorter time to complete healing of venous leg ulcers compared to no compression, with moderate-certainty evidence 4.

Adherence to Wearing Compression Stockings

• Patient adherence to wearing compression stockings is low, and poor adherence contributes to recurrence and impaired healing of venous leg ulcers 6.
• A scoping review found that multidimensional interventions show promise in improving adherence, but require further investigation with high-quality trials 6.
• There is a lack of consensus around defining, measuring, and quantifying adherence with compression stockings, resulting in wide variation in reported adherence rates 6.