Compression Therapy for Preventing the Recurrence of Venous Leg Ulcers

Do compression stockings prevent the recurrence of lower extremity venous ulcers?

Compression stockings can reduce the recurrence of venous leg ulcers, based on limited evidence. Higher-grade compression is more effective, but patients are more likely to be noncompliant with therapy.¹ (Strength of Recommendation: B, systematic review of few fair-quality trials.)

Venous ulcers are relatively common in primary care, with an incidence of 1% to 3% in all adults and 4% in patients older than 65 years.² Venous ulcers, also known as venous stasis ulcers, are the most common type of lower extremity ulcers. Compression stockings are a mainstay of venous stasis leg ulcer therapy; compression is also recommended after healing to prevent recurrence.^2,3

Different grades of compression stockings are available, and countries and regions have varying ways of categorizing these grades. This review uses mainly European Union and United Kingdom compression categories. For convenience, these categories have been converted to approximate commercial US equivalents for venous compression: light (ie, 15–20 mm Hg), medium (ie, 20–30 mm Hg), and heavy (ie, 30–40 mm Hg). The United Kingdom classes overlap the US versions, and this is noted in the results. The authors of this Cochrane systematic review examined the evidence for compression interventions, including bandages and hosiery, in preventing the recurrence of venous leg ulcers.¹

This review included randomized and quasi-randomized trials that examined the use of compression bandages or hosiery to prevent recurrent venous leg ulcers.¹ The authors compared different compression types, brands, and grades; bandages vs hosiery; and lengths of compression bandages/hosiery (ie, below knee vs above knee or thigh length). Four new studies were added to the four studies from the previous version of this review.⁴ The eight studies included 1,995 participants (mean age = 58–78 years) with recently healed venous leg ulcers.¹ Most studies had limitations in allocation concealment, intervention blinding, outcome assessment blinding, and other bias (eg, reporting bias, industry funding).

European Union class 3 (ie, US heavy) compression stockings may reduce reulceration compared with no compression over 6 months (absolute risk reduction [ARR] = 24.7%; 95% CI, 11.0%–33.4%; number needed to treat [NNT] = 5; 95% CI, 3–9; one study; n = 153).¹ European Union class 1 (ie, US light) was no different from European Union class 2 (ie, US medium) in preventing leg reulceration at 12 months. United Kingdom class 3 hosiery (ie, US medium to heavy) was more effective than United Kingdom class 2 (ie, US light to medium) at preventing reulceration over 18 months to 10 years (ARR = 18.8%; 95% CI, 8.9%–31.1%; NNT = 6; 95% CI, 3–11; five studies; n = 1,314); however, noncompliance was greater in the United Kingdom class 3 group (ARR = 6.7%; 95% CI, 0.2%–11.0%; number needed to harm for one patient to withdraw from treatment was 14; 95% CI, 9–500; five studies; n = 1,372).

Guidelines from the European Society for Vascular Surgery³ and the Wound Healing Society⁵ recommend lifelong compression at the heaviest amount of compression that can be tolerated by the patient. Clinicians should ensure adequate arterial circulation with pulse examination or vascular studies as needed when using compression therapy to evaluate and treat leg ulcers.^3,5