Compression garments, hosiery or wraps, are used in the treatment and long-term management of chronic oedema (usually following compression bandaging), prophylaxis and treatment of venous leg ulceration, and post DVT to prevent post thrombotic syndrome. They may also be used with caution for diabetic foot ulceration with oedema, or cardiac oedema (heart failure).

Compression applies graduated pressure to the leg with the highest pressure at the ankle, gradually reducing towards the knee. Compression increases venous blood flow up the leg allowing fluid to drain from the tissues into the venous and lymphatic system, thereby reducing oedema.

Assessment

Before prescribing compression stockings:

• Take a detailed medical and surgical history (refer to NICE CKS for aspects to consider).
• Assess the person's legs for signs of venous disease and oedema (exclude non-venous causes).
• Exclude arterial insufficiency (see vascular assessment below)
• Check the condition of the skin (fragile skin may be damaged while trying to put on or take off compression stockings).
  • Ideally, venous ulcers should be healed before using compression stockings.
• Consider whether the person has reduced mobility and dexterity which may make putting on or off stockings difficult.
  • Consider whether an application aid, or support from community nursing staff is required.

Compression stockings should NOT be offered to people who have:

• Suspected or proven peripheral arterial disease (see also Intermittent Claudication CRG)
  • South Devon & Torbay
  • Western locality
• Peripheral arterial bypass grafting.
• Peripheral neuropathy or other causes of sensory impairment.
• Any local conditions in which compression stockings may cause damage (for example, fragile skin, dermatitis, gangrene, or recent skin graft).
• Known allergy to the material of the stockings.
• Severe leg oedema.
• Major limb deformity or unusual leg size or shape preventing correct fit.
• Acute infection of the leg or foot.
• Suspected acute deep vein thrombosis.
• Suspected skin cancer.

Vascular assessment

Applying a compression bandage to a limb that has arterial insufficiency could lead to pressure damage, limb ischaemia, and even amputation.

Measure Ankle Brachial Pressure Index (ABPI) in both legs using a Doppler machine prior to commencement of full compression therapy. ABPI measurement must be done by a competent healthcare professional who has had the appropriate training.

If there is diagnostic uncertainty — refer for specialist vascular assessment (to a leg ulcer clinic, tissue viability clinic, or a vascular specialist depending on clinical judgement and availability) or to dermatology.

Compression hosiery is extremely effective when being worn, however it does not repair damaged valves or vein walls. Consider referral for varicose veins.

If it is not possible to obtain an ABPI due to oedema, in the absence of any contraindicating factors (see above) apply compression therapy (up to 20 mmHg e.g. Class 1 British standard – see below) to reduce the oedema. Follow up and attempt to obtain an ABPI 1 week later.

Review

Patients with compression treatment should be monitored, and adjustments made to the compression, e.g. size, type, class, colour, correct positioning according to individual needs. This should be assessed at each patient contact as treatment progresses. Well leg patients should be seen every 6-12 months, as required, and reassessed for hosiery including repeat Doppler.

Ensure that the person understands the reasons for, and the benefits of, wearing compression stockings.

Patients should be shown how to apply compression hosiery and garments. For patients having difficulty:

• Putting on compression stockings first thing in the morning may be easier (before any leg swelling develops).
• With class 3 hosiery, wearing a class 1 plus a class 2 stocking will provide a similar level of support.
• Hosiery application aids can be considered to reduce the amount of physical effort involved, which may increase compression use compliance and aid independence.

Classification of compression hosiery

Compression hosiery comes in a range of shapes, sizes and classification testing standards, such as BS (British Standard) and RAL (German Institute for Quality Assurance and Certification).

Compression class relates to the amount of compression provided (mmHg). British Standard garments provide less compression than German RAL (often referred to as European standard) alternatives. British Standard is highly elastic and therefore are not suitable for patients with moderate limb swelling/oedema but is suitable for a ‘normal’ shaped leg, with little oedema. RAL garments are stiffer allowing for better management of oedema.

When prescribing compression hosiery, ensure that consideration is given to the amount of compression required, regardless of classification (see tables below to guide choice, and reduce prescribing errors).

BS has clinical effectiveness of 3 months. German RAL has clinical effectiveness of 6 months.

Flat and circular knit

There are two methods of manufacturing compression hosiery / garments:

• Circular knit garments have no seams. The knit is fine, and garments are soft and stretchy making application easier. Circular knit garments may be particularly useful for low-risk patients who develop oedema as a result of a range of venous conditions. This type of hosiery may cause the development of tight bands around the oedematous region, especially in patients with soft pitting oedema. However, patients who are concerned about the appearance of the garment may prefer the sheer look of these. Unisex compression socks may help with patient concordance.
• Flat knit garments have a seam and are usually made to measure. These are available in unlimited shapes and sizes. They are particularly useful for patients with unusual, shaped limbs and lymphoedema / lympho-venous disease. They are made up from inelastic fibres and control chronic oedema by their stiffness. They may be recommended for chronic oedema / lymphoedema.

Prescribing of compression hosiery

Before elastic hosiery can be dispensed, the product length (below knee or thigh length), quantity (single or pair), compression class, knit (circular or flat), and manufacturer must be specified by the prescriber.

Length

The choice of stocking length should be determined by the person's preference in addition to the clinical presentation.

Below knee compression stockings are recommended:

• To prevent recurrence of venous leg ulcer in patients where leg ulcer healing has been achieved.
• When swelling is limited to the lower leg, or if use of thigh length stockings is not possible or desirable.

Consider thigh length stockings or tights in people with severe varicose veins above the knee or who have swelling which extends above the knee.

Open / closed toe

The choice of open or closed toe stocking mainly depends on the person's preference.

Open toe stockings may be preferred for people who:

• Have arthritic or clawed toes, or fungal infection.
• Prefer to wear a sock over the compression stocking.
• Have a long foot size compared with their calf size.
• Have regular podiatry/chiropody appointments.

Duration of use

Some patients may benefit from wearing a form of compression only during waking hours, and others for 24 hours a day.

Compression stockings should generally be taken off at bedtime and put back on first thing in the morning (before any leg swelling develops or worsens), but can be slept in if preferred, up to a maximum of 7 days. This may be particularly beneficial for patient with impaired dexterity.

Compression stockings should be replaced every 3–6 months and prescribed in two pairs, so that one can be worn while the other is being washed and dried.

The stocking should be replaced earlier if any defects or damage become apparent or if on stretching, the stocking does not return to its original shape.

Ideally, each time a stocking is replaced, the leg should be re-measured.

The life of the stocking can be prolonged by correct washing. Stockings should be hand washed at about 40°C (a comfortable hand temperature) and dried away from direct heat.

Made-to-measure

Occasionally, ready-made stockings are not suitable and custom-made stockings will be required, e.g. due to irregular limb dimensions or if a correctly sized ready-made stocking cannot be obtained from leg measurements.

For those patients with measurements or limb shapes not fitting standard garments, advice and guidance can be sought from specialists.