Clinical Question

Is compression therapy with bandages, stockings, or other devices safe and effective for treating venous ulcers in adults?

Evidence-Based Answer

Compared with treatment featuring no compression, therapy involving compression bandages or stockings results in faster and more complete ulcer healing over 12 months, reduced pain, and improved disease-specific quality of life. It is unclear whether compression increases adverse effects or is cost-effective.¹ (Strength of Recommendation: B, inconsistent, limited-quality patient-oriented evidence.)

Practice Pointers

Leg ulcers are open skin wounds that typically develop on the medial lower leg between the ankle and knee. Chronic leg ulcers can last weeks, months, or years. They often occur due to arterial or venous insufficiency or both, or other less common conditions.¹ Prevalence is unknown, but data from the 1980s suggest that 2 to 3 per 1,000 people have an active leg ulcer, and, in the United Kingdom, the rate increases with age to approximately 20 per 1,000 people older than 80 years.² Venous ulcers can be associated with pain, impaired mobility, reduced quality of life, and considerable health care costs. The authors of this Cochrane review sought to determine how compression therapy with bandages or stockings affects chronic venous ulcer healing and quality of life. Secondary outcomes included adverse effects, pain scores, and the cost-effectiveness of compression therapy.

This Cochrane review included 14 randomized controlled trials with 1,391 participants between 58 and 76.5 years of age. Participants were randomized to receive compression bandages or stockings, including short-stretch bandages, four-layer compression bandages, and an Unna boot, or venous ulcer treatment without compression therapy. The studies were conducted across nine countries, including the United Kingdom, the United States, and Hong Kong, and lasted 12 weeks on average. The participants were treated in outpatient and community settings; most (65.9%) had a confirmed history or clinical evidence of chronic venous disease or an ankle-brachial index (ABI) of greater than 0.8 or 0.9 (an ABI less than 0.8 indicates significant arterial disease or mixed arterial/venous disease).³

Participants treated with compression therapy were nearly twice as likely to heal quickly compared with those not treated with compression therapy (pooled hazard ratio = 2.17; 95% CI, 1.52 to 3.10; n = 733). Participants who had compression therapy were also more likely to experience complete ulcer healing within 12 months compared with the control group (relative risk = 1.77; 95% CI, 1.41 to 2.21; n = 1,123).

Secondary outcomes included pain reported using a 10-point visual analog scale or similar scales. Not all data could be analyzed because of heterogeneity, although the pain scores trended lower in participants treated with compression therapy. Among patients in studies that could be analyzed, those treated with compression therapy had lower mean pain scores vs. those not treated with compression (mean difference = −1.39; 95% CI, −1.79 to −0.98). Four studies (n = 859) measured the participants' quality of life using standardized questionnaires, including the 12-item short-form health survey, the 36-item short-form health survey, the EuroQol-5 Dimension questionnaire, and the Charing Cross Venous Ulcer Questionnaire. Compression therapy helped improve disease-specific quality of life but no other aspects of general health during the 12-week to 12-month follow-up. The reviewers did not draw a conclusion about the differences between specific individual compression therapies. The evidence was uncertain about the risk of adverse effects and the cost-effectiveness of compression therapy.

Although additional studies to determine the relative therapeutic results and cost-effectiveness of different compression therapies will be beneficial, the Society for Vascular Surgery and American Venous Forum Joint Clinical Practice Guidelines Committee recommend that compression therapy be used for the treatment of chronic venous ulcers when there is no evidence of severe underlying arterial disease (i.e., an ABI greater than 0.5).⁴ One low-cost (approximately $10 per dressing) option is the Unna boot, which can be applied in a primary care setting by trained staff supervised by the treating clinician and must be changed weekly.

The practice recommendations in this activity are available at https://www.cochrane.org/CD013397.