Compression for Treating Venous Leg Ulcers

TYPES OF TREATMENT FOR VENOUS LEG ULCERS

Treatment of venous ulcers focuses on four separate but interrelated categories:

1. Compression to treat the Chronic Venous Insufficiency;
2. Wound care – the ulcer surface;
3. Surrounding skin care, and
4. Treatment of pain associated with the ulcer.

1. COMPRESSION

Swelling (edema) is primarily caused by high venous pressure. High blood pressure in the veins is also known as venous hypertension.

Compression bandaging

It is widely recognized and documented that venous leg ulcers require compression of the lower leg to heal effectively. Compression reduces the swelling (edema) in the lower leg, reduces pain, and helps the blood to move out of the leg back to the heart.

Compression provides a counter force to venous hypertension and forces small blood vessels to shrink back to normal so that fluid and cells no longer leak out of the blood vessels and oxygen and nutrients can be transported in the normal fashion.
Compression is required to aid the restoration of normal blood flow to the lower leg. Before healing can occur, it is necessary to reduce the swelling (edema) in the leg.

There are two types of compression used: rigid bandages (short stretch) have little stretching capacity, while elastic bandages (long stretch) are less rigid and contain more stretching capacity.

Rigid (inelastic) compression

Unna’s Boot

In this common form of treatment, a moist bandage is wrapped around the lower leg and covered with another bandage to keep the moist bandage protected from soiling. The moist bandage usually contains a zinc oxide base and may contain other ingredients to assist in providing moisture and reduce skin irritation.

It is important to remember that the Unna’s Boot works best when combined with exercise such as walking. One should stay active and not expect the bandage to do all the work.

There are other types of rigid compression treatments but this is the most common.

Elastic compression

You can recognize elastic bandages by the way they stretch and pull back when you release them. Elastic bandages supply pressure to the leg when applied. They work with your muscle pumps and provide constant compression when exercising. They are designed to provide an external counter pressure that works to reduce the effect of the high venous pressure that led to the ulcer.

There are two main types of elastic bandages to treat venous ulcers: moderate compression elastic and high compression elastic.

Elastic bandages may also be used in the new multi-layered compression systems.
High compression elastic bandages feel strong when you stretch them and may have little squares or indicators that allow you to determine when you have stretched them properly.

They are often applied by themselves over a padding bandage. They may need to be removed at night and put on again first thing in the morning. Some bandaging systems may be worn for up to a full week. A health care professional will be the one to determine how long to wear the compression bandaging system.

Moderate compression bandages do not feel as strong when you pull them on and usually don’t supply enough compression when used alone. They are often used as part of a multi-layer compression system which allows continued compression even after the swelling subsides.

Several multi-layer compression systems are available that take advantage of the different properties of individual layers. They may vary in layers; some contain three while others contain four. Most are left on for up to a week to keep the leg under continuous compression.

One might think that because of all the pressure they put on the leg, compression bandages would be uncomfortable. In fact, most people find they are more comfortable and have less pain when their leg is under compression. By providing a counter pressure to the venous hypertension, they keep swelling down, improve the blood flow to the leg and reduce the damage and pain caused by the stretching of the blood vessels.

Key principles of compression bandaging:

Compression bandaging should not be used if there is arterial disease and leg ulcers. More damage can occur in the ulcer or within the blood circulation system.

• There should be graduated compression – greatest at the ankle while decreasing as it is applied up the leg. Compression is measured in millimeters (mm) of mercury (Hg). Although everyone’s needs are different, the general rule is 32 to 42 mm Hg at the ankle (if tolerated) and ending with 12 to 17 mmHg below the knee.
• Overly tight bandaging should be avoided. This may cause too much constriction resulting in persistent pain.
• Compression to the ulcerated area alone is ineffective.
• The bandage must be applied from the toe to the knee, molding around the ankle, up to the level just below the knee.
• The bandage must not be applied directly to the ulcer or to skin which is damaged or inflamed. A dressing or a paste bandage must act as a buffer.
• After healing, further compression may be necessary to prevent recurrence. At this point a compression stocking may be appropriate.
• Co-operation on the part of the patient is absolutely vital when using a compression bandage. For example, the elevation of the legs just above the heart helps the compression treatment.

Compression hosiery (stockings)

Compression hosiery works collaboratively with the calf muscles for a dual effect, which helps the venous valves to close. The weave and the fabric of each stocking create slight recoil tension, thereby exerting a constant, gently pressure on the limb.

The action of the stocking pushes inwards onto the limb, while the calf muscles push outwards. The benefit of this dual effect assists the venous valves to close and sufficiently return blood and fluids back to the heart.
Additionally, the stocking prevents further fluid build up. Pain and swelling are reduced and comfort is improved, while further ulcer development is avoided.

There is a wide range of compression hosiery available in different brands, shapes, sizes and styles. Compression hosiery comes in knee-high, thigh-high, and full pantyhose styles. It is important to choose the appropriate compression in order to achieve consistent therapeutic benefit.

Four Categories of Compression Hosiery

1) Support Wear:
Contains a very mild compression of 8-5 mmHg

• Tired aching legs
• Mild swelling
• Prevention for people who are required to stand or sit in one position for long periods of time.

2) Medical Leg Wear:
Available in compressions from 15-50 mmHg

• Management and prevention of venous leg ulcer minor to severe varicosities
• Minor to severe edema (swelling)
• Post-surgery and sclerotherapy (veins removed)
• Pregnancy related edema and varicosities
• Lymphatic edema
• Management of Chronic Venous Insufficiency

3) Custom Wear:
Available in compression of 15-90 mmHg

• Patients with abnormal limb shapes
• Patients who need an unlimited size range
• Patients who need specific garment options to improve compliance and fit
• Patients who need long-term management of lyphedema or vascular edema

4) Ulcer Care:
Contains a compression of 40 mmHg

• Designed specifically for use with venous ulcerations
• Two-part system providing a total pressure of 40+ mmHg
• Liner holds dressing in place, is easy to put one, is worn 24 hours a day, facilitates donning of outer stocking
• Is used until the ulceration heals
• Outer stocking has zipper to facilitate donning and is worn during ambulation over the white liner
• Open toe stocking

The venous hypertension which caused the leg ulcer does not go away. Once the ulcer has healed, the person will need to wear these stockings as a preventive measure in order to keep compression on the leg whenever they are not lying down.
As with a compression bandage, the correct fitting of the stocking by a professional is vital for a successful health outcome.

A follow-up appointment is usually arranged after the hosiery has been fitted to ensure that the stocking is being used properly. Regular review may be required to check for any problems.
Ideally, new hosiery should be re-ordered every four to six months.