Advances in Compression Therapy for Treatment of Venous Leg Ulcers

Venous leg ulcers (VLUs), or venous stasis ulcers, remain one of the most common types of chronic wounds, impacting nearly 3 million people worldwide (including more than 2 million Americans annually). Once developed, venous ulcers can persist for weeks or months, have a profound impact on the patient’s quality of life, and place a costly burden on both the patient and the healthcare system. Typically, patients living with VLUs face significant risk of recurrence despite best therapies.¹ However, patients at risk of developing VLUs can lower that risk through effective management of edema associated with venous insufficiency. Clinical studies have shown compression therapy can significantly increase VLU healing rates and reduce the likelihood of recurrence.² This article will explore the century-long evolution of compression therapy and shed light on innovations that provide opportunities for wound care clinicians to create a more customized, comfortable VLU treatment plan for their patients.

Compression Therapy’s Origin

While compression therapy techniques used today have been available for more than 100 years, there have been a number of recent advances that can effectively expand the range of treatments available to clinicians. While some historians claim that forms of compression therapy have been recorded from as early as the time of Hippocrates (460–377 B.C.),³ the first compression bandage was introduced in the 1880s. This gauze bandage, referred to as the Unna’s boot, was named after German dermatologist Paul Gerson Unna (1850-1929), a German physician who specialized in dermatology and is regarded as one of the pioneers of dermatopathology. The “boot” typically includes a roll gauze that’s impregnated with zinc oxide paste, which is believed to provide moisture, promote healing, and soothe discomfort from dermatitis and other skin-related irritations associated with venous ulcerations. The boot is then often covered by an elastic or self-adherent elastic bandage. 

The Unna’s boot remained the main method for compression therapy until the late 1980s, when the first four-layer system emerged at Charing Cross Hospital in London. The first of the four layers is an orthopedic wool covering used to absorb exudate and redistribute pressure around bony prominences. This is followed by a layer of padding for comfort and conformability. Elastic bandages complete the final two layers to help establish specific levels of compression. These more traditional compression therapies are still utilized today, but patients tend to describe them as bulky, hot, and painful, making them incompatible with daily activities.⁴ Patients also find that they loosen and slip down the leg, thus losing their compression and resulting in ineffective treatment. Bandage slippage can also increase the potential for skin irritation and require more frequent compression dressing changes. The challenges of these pioneering technologies can lead to higher rates of patient noncompliance with compression therapy, which can translate to VLU healing times that can take twice as long.⁵

Today’s Compression Therapy

Thankfully, traditional treatment options have steadily evolved over the past 15-20 years. Multi-component and two-layer compression therapy systems, or short-stretch compression therapy systems, entered the market roughly 10 years ago and have advanced the ease of bandage application for clinicians while providing them with products that deliver effective therapeutic compression. New, advanced two-layer compression systems provide a thin, lightweight, rigid sleeve that typically uses a foam layer for comfort and gripping the skin. A second, non-latex, inelastic layer for compression and coherence to the first layer is also offered. These bandages are low profile and are more comfortable to wear, enabling more patients to wear their own shoes and maintain normal daily routines. The two-layer system can also generate a sustained, high active pressure (or “working pressure”) and a sustained, low resting pressure, which can make the compression easy to tolerate regardless of activity level. The sustained, therapeutic compression can last for up to seven days and is available in a variety of sizes to accommodate larger leg circumference. This provides greater comfort for patients, especially during sleep, and greater effectiveness in delivering therapeutic compression. These types of short-stretch compression therapy systems can also be used on patients living with mild to moderate arterial disease. A “lite” two-layer compression system would be appropriate for an ankle-brachial pressure index (ABPI) between 0.5 and 0.8, providing 25-30 mmHg of resting pressure. And for patients with an ABPI of ≥ 0.8, a regular two-layer system would be appropriate, providing 35-40 mmHg of resting pressure. These benefits can increase the likelihood that patients will actually wear the bandages, thus increasing compliance and the potential for more effective treatment.^6-9 In fact, a retrospective analysis from the United Kingdom found that one two-layer system has been shown to result in increased healing rates and a lower cost of treatment compared to a four-layer system when patients started in the two-layer system.¹⁰

Difference Between Long-Stretch & Short-Stretch

With chronic venous insufficiency or chronic venous hypertension, patients have unrelieved elevated venous pressure when walking. The goal of compression therapy treatment for these patients is to return venous pressure to normal levels under all circumstances, whether the patient is sitting, lying, standing, or walking. The approach to returning venous pressure to normal under all circumstances has led to a variety of approaches. Long-stretch, or “elastic” compression, uses elastic materials that can stretch to more than 100% of their original length. By comparison, short-stretch, or “inelastic” compression, uses materials that typically stretch from 5-40% of their original length. The difference in function between elastic and inelastic systems will be reflected in the venous pressure that results from their use. The true measure of the success of compression therapy would require an invasive assessment of venous pressure, which is impractical and not performed. In practice, the interface pressure between the bandage and the skin is used to describe the function of the bandage. The goal is to have an interface pressure that is low while the patient is in the supine position and high while the patient is in the standing position. Short-stretch systems are typically composed of two layers and form a system that can achieve these clinical goals. While the systems are of value, they are only part of the solution — proper application of the short-stretch bandage is critical to its success. Bandage systems have been designed to remove the guesswork from the application of the layers, resulting in consistent levels of applied compression.¹¹

Future of Compression Therapy

VLUs are a more significant problem for those aged 65 and older. According to the U.S. Department of Health and Human Services’ Administration on Aging, people aged 65 and older represented 14.5% of the population in 2014, but that number is expected to grow to 21.7% by 2040. With an aging population, including many people who lead very active lifestyles, additional advancements in compression therapy will be needed to continue to keep pace.  VLUs are, and will likely continue to be, managed by a number of different clinicians. In today’s care model, this can sometimes lead to inconsistency in referral pathways, diagnoses, and treatments. As healthcare delivery as a whole continues to evolve, including applied philosophies of consumer-driven healthcare, we may see a shift toward evidence-based compression therapy wraps and devices that can be more easily self-administered.

Moving Compression Forward

As the science of compression continues to unfold, the next step is to encourage wider adoption of compression therapy as the “gold standard” for VLU treatment. In 2014, venous disease experts from around the world convened to address this issue. The group simplified key principles on the topic and agreed on an ideal compression therapy system.¹ Ideal compression therapy should:^1,4

• deliver therapeutic compression and have high stiffness (ie, the pressure generated is effective during mobilization and is well tolerated during rest), 
• permit good anatomical fit,
• stay in place (ie, does not slip),
• be comfortable,
• allow patients to wear their own shoes and maintain normal gait,
• be easy to apply and remove, and
• require minimal training in fitting and application.

Even the smallest advances in compression therapy have the potential for clinicians to treat their patients’ VLUs faster and easier while improving comfort and compliance. These advances include technology and personal commitment. Properly identifying patients who will benefit from compression therapy and learning the proper methods of compression application will help to form part of the solution to improved VLU care. Wound care providers should take the time to educate themselves on the latest application methods and benefits of different compression bandage systems to help patients get “back on their feet.” 

Pat Parks is an adjunct associate professor in the department of experimental and clinical pharmacology at the University of Minnesota and is the medical director of the critical and chronic care solutions division at 3M, Maplewood, MN. His passion and responsibilities include research and technologies for to catheter-related bloodstream infections and wound healing.

References

1. Harding K, Dowsett C, Fias L, et al. Simplifying Venous Leg Ulcer Management: Consensus Recommendations. Wounds International. 2015. Accessed online: www.woundsinternational.com/consensus-documents/view/simplifying-venous-leg-ulcer-management

2. Nelson EA, Bell-Syer SE. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2014;9.

3. Negus D. Historical Background. In: Leg Ulcers: A Practical Approach to Management. Oxford, UK: Butterworth-Heinemann;1991:3-10.

4. Edwards LM. Why patients do not comply with compression bandaging. Br J Nurs. 2003;12(11 Suppl):S5-10.

5. Moffatt C, Kommala D, Dourdin N, Choe Y. Venous leg ulcers: patient concordance with compression therapy and its impact on healing and prevention of recurrence. Int Wound J. 2009; 6(5):386–93.

6. Moffatt CJ, Edwards L, Collier M, et al. A randomized controlled 8-week crossover clinical evaluation of the 3M Coban 2 Layer Compression System versus Profore to evaluate the product performance in patients with venous leg ulcers. Int Wound J. 2008;5(2):267-79.

7. Schuren J, Andreas C. Pressure and Slippage During 48 Hours of Compression Therapy: A Study on Healthy Volunteers. Poster presented at: SAWC/WHS Spring; April 2010; Orlando, FL.

8. Hampton S, Kerr A, Crossley M. Summary of Five Case Studies on the Treatment of Venous Leg Ulcers With a New Two-layer Compression System in a Community Setting. Tissue Viability Consultancy Services. 2006. Accessed online: https://multimedia.3m.com/mws/media/384932O/coban-2-layer-compression-system-summary-of-5-case-studies.pdf

9. Schnobrich E, Solfest S, Bernatchez S, Zehrer C, Tucker J, Walters SA. 7-Day, In-Use Assessment of a Unique, Innovative Compression System. Poster presented at: SAWC 2006; August 2006; San Antonio, TX.

10. Guest JF, Gerrish A, Ayoub N, Vowden K, Vowden P. Clinical outcomes and cost-effectiveness of three alternative compression systems used in the management of venous leg ulcers. J Wound Care. 2015;24(7):300-8.

11. Collier M, Schuren J. Ease of use and reproducibility of five compression systems. J Wound Care. 2007;16(suppl):S8-10.