Compression for leg wounds H. Partsch 1 and P. Mortimer 2

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1 SCHOLARLY REVIEWS Compression for leg wounds H. Partsch 1 and P. Mortimer 2 1 Department of Dermatology, Medical University of Vienna, Vienna, Austria 2 Department of Dermatology, St George s Hospital, University of London, London, U.K. BJD British Journal of Dermatology Summary Correspondence Hugo Partsch. Hugo.Partsch@meduniwien.ac.at Accepted for publication 27 January 2015 Funding sources No external funding. Conflicts of interest None declared. DOI /bjd The main points in this scholarly review on the use of compression therapy in leg ulcers are the different modes of action of this treatment and the tools that are available including their practical applicability and use for self management. Due to its effect of counteracting gravity, compression is also suggested for ulcers with aetiologies that are not usually thought to require compression. The clinical evidence reported in ulcer-healing studies are discussed and some considerations are made relating to the cost-effectiveness of this management. In general, the failures of compression therapy are not caused by poor compression material but due to poor knowledge and application techniques of the care providers. Future studies comparing different compression devices should also report details concerning the compression material used and the pressure exerted. Gravity is the prominent underlying reason why most ulcer wounds are located on the lower legs. Compression counteracting gravity is therefore the most reasonable basic remedy and is still considered to be a cornerstone for managing leg wounds. This is true not only for a predominant category of venous leg ulcers caused by venous reflux and/or obstruction (Fig. 1) but also for leg wounds of other origins. Because venous stasis in the upright position plays a major role in the formation of leg ulcers, compression may also be helpful in such nonvenous cases, for example in leg ulcers due to sickle cell anaemia; it has been shown that such ulcers showing no improvement with haematological therapy may heal with proper compression bandages (Fig. 2). 1 How does compression work? The amount of compression applied to an extremity is defined by the force of the compression applied to a certain area. Following the law of Laplace, the resulting compression pressure is directly proportional to the tension of the applied fabric and indirectly proportional to the radius of the limb. This means that the same force applied to a sharp curvature (low radius) will produce a higher pressure than when applied over a slightly curved structure (large radius) and thus the pressure will be zero over a completely flat part of the leg, e.g. the plane part of the shin. An example for the practical relevance of the law of Laplace is given in Figure 3. A pad applied over the ulcerated area behind the inner ankle increases the pressure due to a decrease of the local radius of the leg. The resulting force of a single layer depends on the elastic property of the product and the applied stretch. The pressure exerted by inelastic material with no extensibility (e.g. zinc paste) is created only by the strength exerted during application. Adding several layers increases the pressure. External compression will affect all deformable structures of the extremity, i.e. the blood and lymphatic vessels and the fluid content in the tissue. The main effects of compression are summarized in Box 1. 2,3 Oedema reduction The fact that compression reduces oedema is so well accepted means that up to now proof by randomized controlled trial (RCT) has not been considered necessary. Clinical investigations focusing on a dose response relationship have revealed that in patients with chronic leg oedema, there is a correlation between exerted pressure of compression stockings and oedema reduction in a pressure range between 10 and 40 mmhg. However, bandages applied with pressures between 60 and 90 mmhg achieved an inverse correlation with less oedema reduction under very high pressure. 4 In patients with breast cancer-related lymphoedema of the arms, Damstra and Partsch showed that compression bandages applied with pressures of < 30 mmhg were more effective than those with more than 50 mmhg. 5 This apparent paradox is most likely due to the different action profiles of compression regarding venular filtration and lymphatic drainage: the optimal pressure to reduce fluid filtration in the venules depends on the pressure gradient between the position-dependent intravenous pressure and the tissue pressure and 359 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.

2 360 Compression for leg wounds, H. Partsch and P. Mortimer (a) (a) (b) (b) (c) Fig 1. (a) Venous ulcer (post-thrombotic syndrome with refluxes in superficial and deep veins) presenting typical clinical features: localized at the medial ankle region, and surrounded by inflamed, lipodermatosclerotic skin with some yellowish crusts. The ulcer crater is deep and shows a necrotic yellow centre. (b) Ten weeks after compression therapy with Unna boot bandages and a rubber foam pad in order to increase local pressure, and the ulcer is healed. In the first week, the bandages were changed twice, later on, at weekly intervals. The patient was instructed to walk as much as possible. The edge of the ulcer scar still presents signs of the local compression showing hyperpigmentation. Simple absorbing, nonadhering dressings and tap water for cleaning were used, with no debridement or antibiotics. At this stage, compression stockings (21 32 mmhg) were prescribed to prevent ulcer recurrence. is therefore higher in the lower than in the upper extremity. On the other hand, lymphatic drainage can be diminished when the external pressure exceeds the pressure of the lymphatic pump. 6,7 As after bandage application the pressure starts to drop immediately, there are considerable practical consequences concerning the optimal timing of bandage renewal and an optimally effective initial compression pressure. In a recent publication, Moffatt et al. 8 found more effective oedema reduction with bandages applied twice per week compared with application five times per week. This surprising result demonstrates that frequent bandage renewals in a high-pressure range can be counterproductive. Fig 2. (a) Large, medial ulcer in a 58-year-old male suffering from thalassemia intermedia, diagnosed at the age of 6 years. The patient was treated with blood transfusions, iron-chelating agents and by splenectomy at age 13 years. Bilateral leg ulcers developed when he was 38 years old, were treated with ointments and local dressings and persisted for 19 years. 1 (b) Four months after starting compression therapy with short-stretch bandages, initially changed three times per week, later on weekly, the ulcer size has reduced. (c) Ulcer healing after 8 months of short-stretch compression bandages. Pressures lower than 10 mmhg have been shown to prevent evening leg oedema 9 and stockings providing 20 mmhg were demonstrated to be equally effective compared with 60- mmhg bandages with regard to reduction of leg swelling after 2 days in patients with chronic oedema. 10 Compression effects on venous haemodynamics Depending on the transmural pressure gradient between intravenous pressure and external pressure, compression will narrow the veins. Duplex 11 and magnetic resonance imaging 12 have shown that in the lying position, pressures of < 20 mmhg reduce the calibre of superficial and deep veins,

3 Compression for leg wounds, H. Partsch and P. Mortimer 361 Fig 3. Rubber foam pad (Komprex â, Lohmann & Rauscher) to increase compression pressure in the retromalleolar fossa. The curved part should be applied to the skin. Box 1: Main effects of compression 2 Reduction of oedema Reduction of capillary filtration Fluid shift into noncompressed regions Improvement of lymphatic drainage Effects on veins (venous narrowing) Increase of venous blood flow velocity Reduction of venous pooling Improvement of venous pumping function Effects on microcirculation and cytokines Increase of shear stress Release of anti-inflammatory mediators Effects on arterial inflow Increase of arterial flow (intermittent or moderate sustained pressure 3 ) Reduction of arterial flow if compression pressure exceeds the perfusion pressure but that in the standing position, much higher pressures are required to achieve the same result. Interestingly, a more intense reduction of venous diameters of deep compared with superficial veins during standing could be demonstrated, obviously due to the deep compartment pressure that increases during standing. 13 Venous hypertension is the primary pathophysiological cause for the development of venous ulcers. In a vein of the lower extremity, the pressure corresponds to the weight of the blood column between the measuring point and the right heart. The intravenous pressure measured in a dorsal foot vein of a normally sized adult is between 80 and 100 mmhg in the standing position, depending on the body height. Under normal conditions this pressure drops to values of < 30 mmhg when the individual starts walking. With every muscle contraction during walking, blood is shifted against gravity towards the heart while intact venous valves prevent reflux during muscle diastole. In most patients with venous ulcers, the intravenous pressure drops much less due to incompetent valves, a situation which is called ambulatory venous hypertension. Venous hypertension may also be caused by severe outflow obstructions, e.g. patients who are massively overweight. 14 A few studies have shown that compression is able to reduce ambulatory venous hypertension. 15,16 By measuring the pressure in a dorsal foot vein in a group of patients with severe chronic insufficiency we demonstrated that a significant reduction of ambulatory venous hypertension could be achieved by inelastic bandages exerting resting pressures of more than 50 mmhg, not by elastic stockings exerting lower pressures. 16 The haemodynamic effect of inelastic material can be explained by an intermittent narrowing of incompetent veins during muscle contractions during walking, blocking reflux 17 and increasing the ejection fraction of the calf pump. 18 Effects on microcirculation and cytokines Patients with severe stages of chronic venous insufficiency show a decreased capillary density in the gaiter area, 19 which improves after compression therapy, mainly due to oedema reduction. 20 As shown in different studies, compression has anti-inflammatory effects, which may explain the instant reduction of pain in patients with ulcers after application of a proper bandage. Intermittent pneumatic compression leads to an increase of shear stress in the microcirculation and to a release of antiinflammatory, vasodilating and antithrombotic mediators from the endothelial cells. 21 It may be assumed that these effects will also occur during the massaging action of inelastic compression material during walking. In patients with venous leg ulcers, Beidler et al. 22 have shown that ulcer healing achieved by compression therapy is coupled with reduced pro-inflammatory cytokine levels and higher levels of the anti-inflammatory cytokine IL-1 Ra and that elevated matrix metalloproteinase levels are reduced by compression. 23 Lymphatic drainage is impaired in leg ulcers, but microlymphangiopathy has also been shown in lipodermatosclerotic skin areas before ulceration. 24 Compression effects on arterial inflow About 16% of patients with venous leg ulcers have arterial occlusive disease concurrently, which is frequently not recognized. 25 By using a simple pocket Doppler ultrasound device we can measure the systolic ankle pressure which closely corresponds to the arterial perfusion pressure in patients with arterial occlusive disease (see Box 2). In order not to reduce arterial inflow, compression pressure should never exceed the local arterial perfusion pressure. This is one of the reasons why we consider absolute values of the ankle pressure more relevant than the ankle brachial pressure index (ABPI). Therefore, a systolic ankle pressure of 50 mmhg or less is a strict contraindication against compression exceeding these values. Not well recognized is the fact that compression is also able to increase arterial blood flow, even in patients with arterial occlusive disease. Clinically important implications have been demonstrated using two kinds of compression:

4 362 Compression for leg wounds, H. Partsch and P. Mortimer Box 2: Assessment of arterial flow by using a Doppler ultrasound device ( Pocket Doppler ) Patient positioned in recumbency Sphygmomanometer put over the distal lower leg (ankle region) Find the pulse of the posterior tibial artery behind the inner ankle and find the pulse of the dorsalis pedal artery over the dorsum of the foot (use plenty of ultrasound gel) Inflate the cuff until no pulsation can be heard Release the pressure slowly, and notice the first arterial sound; the corresponding pressure is the systolic ankle pressure Repeat the procedure by putting the cuff to the upper arm to measure systolic arm pressure (auscultation of the cubital artery or the radial artery) Ankle brachial pressure index (ABPI) = systolic ankle : systolic arm pressure ABPI No occlusions in large arteries ABPI Arterial occlusive disease ABPI < 05 Critical ischaemia (severe arterial occlusive disease) ABPI > 13 Suspicion of mediasclerosis (diabetes, kidney disease) Use other method, e.g. toe pressure (see Fig. 4), oscillography Fig 4. Mixed arterial-venous ulcer in a patient with deep venous refluxes (postthrombotic syndrome) and femoro-popliteal arterial occlusions (ABPI 06, systolic toe pressure 50 mmhg). A flat Laser- Doppler probe ( ) and an air-filled probe for measuring compression pressure ( ) is attached proximal to the ulcer border, additionally toe pressure and TcPO2 are measured on the dorsum of the foot. Application of inelastic bandages showed a reduction of the arterial flow only when compression pressure exceeded 40 mmhg. 3 ABPI, ankle brachial pressure index 1 Specifically designed intermittent pneumatic compression (IPC) pumps exerting high pressure peaks (130 mmhg) of short duration followed by long phases without pressure are able to increase arterial flow and have been shown to be useful even in patients with gangrene who cannot be revascularized anymore In patients with mixed ulceration (venous ulcers plus arterial occlusions) and an ABPI between 05 and 08 socalled modified compression could be shown to increase Laser-Doppler flux under the bandage without decreasing the toe pressure or TcPO2 distal to the bandage and to improve the venous pump by increasing the ejection fraction (Fig. 4). 3 pressure depends entirely on the force with which it is applied. Layers Bandages are always applied with some overlap and are therefore multilayer by definition. Multilayer bandages are in fact multicomponent bandages. Components Most modern bandage systems consist of different materials, fulfilling different functions, e.g. for padding or to prevent slippage. What compression devices are available? Table 1 gives an overview of different compression devices that have been used and recommended to treat leg ulcers. 27 Bandages The following four parameters determining the quality of a compression bandage have been summarized in the acronym PLaCE in which P stands for pressure, La for the number of layers, C for components and E for the elastic property of each component. 28 Pressure It is a misconception to assign a certain pressure to a specific product, e.g. to call a Comprilan a light-support bandage and Tensopress a high-pressure bandage. Actually, the Elasticity/stiffness The traditional approach to classifying compression bandages is based on the elastic property of the material. Single bandages with a maximal extensibility of < 100% are called short stretch ; those of more than 100% are long stretch. The term inelastic comprises material with virtually no stretch (e.g. Unna boot, see Fig. 5) and short-stretch bandages. Long-stretch material may be called elastic. This terminology should be used only to characterize single bandages, because the elastic behaviour of a bandage on the leg consisting of a mixture of materials can no longer be characterized by these categories. 28 The term stiffness has been proposed to characterize the elastic property of a final bandage on the leg. Stiff, nonyielding material produces high-pressure peaks when the calf muscles contract in contrast to elastic, yielding material. The

5 Compression for leg wounds, H. Partsch and P. Mortimer 363 Table 1 Methods of compression (modified from Gale et al., 27 reproduced with permission) Type (1 4) Description Example Application Advantages Disadvantages Stiffness 1A Inelastic Zinc paste (Unna) Trained staff, may stay for some days 1B 1C Short-stretch Singlecomponent Short-stretch Two-component 1D Short-stretch + long-stretch Multi-component bandages 1E Long-stretch elastic Double Rosidal K â Double Comprilan â Actico â Coban 2 â Profore â (elastic components Comprifore â K Two â (inelastic + elastic components) Surepress â Setopress â 2B Ulcer kits Double stockings, e.g. Activa socks â, mediven ulcer kit â Jobst UlcerCARE â 3 Velcro devices (short-stretch) CircAid â Juxta Cures â Farrow wrap â 4 Extremity pump Variety of products in different versions 5 Hybrid pumps ( adaptive compression therapy ) Actitouch â Combines sustained with intermittent pressure Trained staff, may stay for some days Trained staff, may stay for some days Trained staff, may stay for some days Easy application, needs to be removed overnight Basal layer worn overnight and keeps ulcer dressing in place; second stocking during daytime Self-application Self-adjustable Self-application Self-adjustable Self-application Pressure in sustained mode is maintained High working pressure, well tolerated during rest High working pressure, well tolerated during rest Washable and reusable High working pressure, well tolerated during rest Less slippage High working pressure, well tolerated during rest Self-application Restricted reusability Patient can have showers, daily skin care Self-management Patient can have showers, daily skin care Self-management Patient can have showers, daily skin care Self-management Patient can have showers, daily skin care Self-management Messy Disposable Pressure loss Slippage Pressure loss Disposable Pressure loss Not reusable Bulky and warm Low working pressure Not tolerated when applied with high pressure Difficult to put on Not appealing Works when patient is resting for limited time Adjunctive use only Not appealing Very high High High High Low Medium Medium high Variable Variable increase of the sub-bandage pressure by standing up from the lying position has been called the static stiffness index. Values of < 10 are typical for elastic material; values over 10 characterize stiff material. The pressure peaks during walking ( working pressure ) are slightly higher than the standing pressure (Fig. 6). When different layers of elastic material are applied over each other, the final bandage will become stiff, mainly due to the friction between the layers. This explains the fact that the so-called four-layer bandage is a stiff bandage although its single components are elastic. 29 Compression stockings Positive experience in ulcer treatment has been made with double compression stockings. A basic stocking exerting a pressure of 20 mmhg or less keeps the local ulcer dressing in place and remains in place overnight: a second stocking (20 30 mmhg) is applied over it during the daytime (Fig. 7). 4,30,31 Self-adjustable Velcro devices These systems, consisting of Velcro straps, can be applied and readjusted by the patients themselves and offer great advantages with regard to self-management (Fig. 8). 32 Pneumatic pumps Such pumps can be used at home, especially in patients whose mobility is restricted in addition to sustained compression. 33,34

6 364 Compression for leg wounds, H. Partsch and P. Mortimer Hybrid devices These are a combination of sustained and intermittent pneumatic compression. In sustained mode, pneumatic pressure chambers compress the leg continuously to a pre-set pressure level ( adaptive compression therapy ). During sitting periods the patient can switch to intermittent pressure and will get a massage (Fig. 9). 35 Practical handling of different compression devices Some practical recommendations are summarized in Boxes 3 and 4. Stiff compression Fig 5. Unna boot bandage (zinc paste) wrapped over with a shortstretch bandage as a classic example of an inelastic bandage (Varicex F â + Rosidal K â, Lohmann & Rauscher). Compression pressure is the dosage of our treatment and should be adjusted to individual needs. The ideal compression device should provide a tolerable resting pressure and a pressure high enough to counteract gravity in the upright position. This prerequisite is best fulfilled by using stiff compression products. As shown in Figure 6 there is an immediate pressure increase with every muscle contraction during repeated dorsiflexions and also by standing up. One could say that such stiff materials result in an intelligent compression, which provides high pressures when needed, i.e. in (a) (b) Fig 6. (a) Compression pressure measured under a short-stretch bandage at the transition point of the gastrocnemius muscle into its tendon ( B1 point ). During dorsiflexions pressure peaks go up to 80 mmhg, DSI = dynamic stiffness index = 40 (Picopress â, Microlab, Padova, Italy). Pressure increases from 40 to 73 mmhg by standing up, SSI = static stiffness index = 33. The high amplitudes during muscle contractions achieve a strong massaging effect. (b) Pressure measured at the same leg under a compression stocking. Resting and working pressures are much lower than under a shortstretch bandage (a). The pressure amplitudes during movement are much lower, which means that there is much less massaging effect.

7 Compression for leg wounds, H. Partsch and P. Mortimer 365 Fig 9. Adaptive compression therapy (ACT) using inflatable chambers for sustained and intermittent compression (ACTitouch â, Tactile Systems, Tactile Medical, Minneapolis, MN, U.S.A.). 35 Fig 7. Double compression stocking (mediven ulcer kit â, medi, Bayreuth, Germany) consisting of a white under-stocking to keep the local ulcer dressing in place during the day and night (right leg on the picture) and a compression stocking (left leg on picture) which is applied over the white stocking by the patient during the daytime. Box 3: Compression bandages applied by trained staff: practical recommendations The pressure is in your hands, not in the textile Before applying strong bandages feel the pulse, if you are uncertain measure ankle blood pressure (pocket Doppler) Maximal dorsiflexion during application ( toes towards the nose ); padding of the protruding tendon lifting the foot Avoid over-padding Follow the instructions of the manufacturer Adjust the stretch to the curvature: careful stretch in slim legs, strong stretch in fat legs Let patients walk after application and ask them to come back after some minutes if painful Change when bandage is getting loose or when secretion of the ulcer penetrates (initially twice per week); after decongestion once per week Fig 8. Self-applied inelastic Velcro-wrap (JuxtaCures â, Circaid, medi, Bayreuth, Germany). the upright position. Due to the immediate reduction in oedema the initial pressure drops while stiffness is maintained. 36 This pressure drop needs to be taken into consideration by applying such stiff bandages stronger than bandages containing elastic material, i.e. 60 mmhg or more in patients with ulcers without arterial occlusive disease. As different studies have demonstrated most bandagers apply such bandages much too loosely, 37,38 which is the determining reason for inferior outcomes in some comparative trials. 39 Proper handling of short-stretch material needs appropriate training. The main advantage of the so-called four-layer bandage and for the new two-component systems is achieving acceptable compression also without specialized training. The recommen-

8 366 Compression for leg wounds, H. Partsch and P. Mortimer Box 4: Self-management: practical recommendations Compression stockings Main indication: to keep a healed ulcer closed Small ulcers of short duration may also benefit from compression stockings Use ulcer kits = double stockings Basal stocking keeps ulcer dressing in place and stays on the leg overnight Outer compression stocking is applied over the basal stocking during the daytime Let patients walk after application and ask them to come back after some minutes if painful Allows frequent dressing change and more intense skin care Velcro-band devices if patient cannot put on and remove stockings themselves Can be worn overnight, pressure adjusted by the patient based on subjective feeling dation to achieve a pressure of 40 mmhg in the gaiter region which then will automatically reduce to 17 mmhg over the proximal part at the calf due to the greater radius according to Laplace law is questionable and based entirely on practical experience. 40 Based on measurements in patients with severe chronic venous insufficiency appropriate pressure is required for improving the reduced calf pump function. It has been shown that stiff bandages exerting more than 50 mmhg in the upright position reduce venous reflux 41 and ambulatory venous hypertension 16 and increase the ejection fraction of the calf pump more effectively than lower pressures or elastic material applied with the same resting pressure. 18 Also based on clinical experience, higher pressure is more effective in relation to ulcer healing. 39,42 In a clinical study comparing bandages with different pressures, the highest healing rates of venous ulcers were found with bandages applied with a pressure of more than 70 mmhg. 43 For achieving a high pressure over the ulcer area, special pads or straps 44 may be useful. However, the dogma that compression needs always to be graduated providing higher pressures over the distal than the proximal parts has been questioned concerning venous haemodynamics in the ambulatory patient. In fact, higher pressure over the calf is more important to increase the muscle pump than a graduated pressure 45 but clinical studies in patients with ulcers are needed. Modified compression in patients with mixed ulceration In patients with mixed arterial venous ulcers we recommend the use of modified compression and walking exercises. 3 Modified compression is characterized by inelastic bandages applied with an initial pressure up to 40 mmhg, which should be renewed daily during the initial phase, carefully checking the skin for any sign of damage. Together with walking exercises this treatment regime is a recommendable alternative, especially for patients in whom arterial revacularizing procedures are not an option. This conservative management can also be combined with methods abolishing superficial venous reflux and with ulcer surgery and skin grafting. 46 Compression in immobile patients Elderly and overweight patients are frequently unable to walk. They spend substantial time in wheelchairs and develop increasing swelling of the legs due to immobility. Painful ulcers may also cause patients not to move their ankle joint, which further stiffens. Based on the assumption that inelastic material would be effective only during exercise such patients are still frequently considered to be candidates for elastic material. Actually an inelastic device applied with sufficient pressure will reduce oedema to the same extent as elastic bandages while avoiding the effect of elastic fibres, which would maintain an ongoing constriction of the leg, which may be unpleasant and may cause skin damage, especially in patients with sensory loss such as those with diabetes. In contrast, the pressure of inelastic material will drop immediately with the slightest active or passive movements leading to a massaging effect. 47 Physiotherapy with passive joint movements in addition to stiff bandages is recommended. Maintenance by using elastic material Self-management using compression stockings and ulcer kits may be successful if the ulcers are small (< 5cm 2 ) and if the ulcer duration is < 6 months. 48 Two stockings applied over each other equate to the pressure of a very strong compression stocking but are easier for the patient to put on. The most important indication for compression hosiery is the challenge to keep healed ulcers intact. Thus, in prescribing stockings, the highest tolerated pressure is recommended. 49 Compliance in wearing the stockings is crucial and can only be achieved by motivation and counselling of the patients. The cooperation of the patient may be supported by diaries containing wearing time of stockings and tape measurements of leg circumference. A newly developed hybrid device combining sustained and intermittent compression comes with an automated pressure-tracking feature allowing for an accurate assessment of the patient s use of the system. 35 Such devices may be helpful to improve patient compliance. In patients in whom venous refluxes have been corrected follow-up visits may reveal that further daily wearing of hosiery might not be necessary. Self-management with Velcro devices A good indication for Velcro-band devices is the patient who, after bandaging, cannot maintain the positive effects by using

9 Compression for leg wounds, H. Partsch and P. Mortimer 367 hosiery or who is unable to put on and remove compression stockings. Also in the acute ulcer stage, such Velcro devices may be recommended for patients who prefer self-management. 32 Intermittent pneumatic compression and hybrid systems Basically, IPC mimics the action of stiff bandages plus walking exercises. In addition to sustained compression by using bandages, IPC pumps may be beneficial, especially in patients with restricted mobility. 33 The pumps can be applied over a bandage and should be used for at least 2 h per day. 34 What is the clinical evidence for compression therapy in leg ulcers? The efficacy of compression therapy for managing venous ulcers specifically has been demonstrated in many RCTs and meta-analyses. 39,42 The most relevant primary outcome parameters are the time to complete healing and the proportion of ulcers healed within the trial period. The evidence derived from these publications needs to be interpreted with care. Usually the wound origin in patients enrolled into such studies is not based on a clear proof of venous pathophysiology, but rather on excluding (concomitant) arterial disease. By excluding a considerable part of the population with ulcers the outcome of these published RCTs often poorly reflects reality. Another substantial disadvantage of these investigations is that neither operator skill nor the dosage corresponding to the pressure of the different devices is considered and therefore proper compression systems are frequently compared with weak, poorly applied materials. A Cochrane review providing the most complete overview on RCTs of compression treatment in venous leg ulcers concludes with the following statements: 42 1 Compression increases ulcer healing rates compared with no compression. 2 Multicomponent systems are more effective than singlecomponent systems. 3 Multicomponent systems containing an elastic bandage appear more effective than those composed mainly of inelastic constituents. 4 Two-component bandage systems appear to perform as well as the four-layer bandages (4LB). 5 Patients receiving the 4LB heal faster than those allocated to the short-stretch bandages (SSB). 6 More patients heal on high-compression stocking systems than with the SSB. 7 Further data are required before the difference between high-compression stockings and the 4LB can be established. The authors concede that the differential effects of different bandage types are partly confounded by the skill and experience of the bandagers. As three out of the five included trials (representing 75% of included participants) were based in the U.K., where the 4LB is standard, this might explain the superior results published with this technique. 42 Comparative trials between short-stretch and four-layer bandages performed in centres with short-stretch tradition have shown no difference 50,51 or even superior results in the shortstretch group. 52 Two-component compression bandages seem to be similarly effective and especially, the adhesive materials used as the outer layer seem to offer a less bulky alternative allowing better ankle mobility and excellent ulcer-healing rates. 53 Such bandages provide a similar stiffness as short-stretch bandages, which make comparisons difficult. The superiority of stockings compared with different bandage systems in ulcer healing shown in two meta-analyses 30,31 can mainly be explained by the fact that in most analysed papers good stockings have been compared with poor bandages. Cost-effectiveness The most expensive single factor driving costs is the manpower of the medical personnel performing compression. Selfmanagement is a solution, so that even the higher costs for Velcro devices may be justified. Concerning the costs for the other compression materials, the deciding question is if the material is disposable or if it can be washed and reused. This answer depends on the local hygiene requirements, which may be different across centres. An example of discrepant interpretations is the comparison of two studies in which a four-layer and a short-stretch bandage were compared, one coming from the U.K. and the other from Hong Kong. In the Venus I trial both bandage types were disposed of after every bandage change 54 while in Hong Kong, this was done with the four-layer bandage only while the short-stretch bandage was washed and reused. 52 This led to conclusions which were quite opposite: four layers were considered more cost-effective in the U.K., short-stretch in Hong Kong. References 1 Fracchia E, Elkababri M, Cantello C et al. Venous-like leg ulcers without venous insufficiency in congenital anemia: successful treatment using compression bandages. Dermatol Surg 2010; 36: Partsch H. Compression therapy: clinical and experimental evidence. Ann Vasc Dis 2012; 5: Mosti G, Iabichella ML, Partsch H. Compression therapy in mixed ulcers increases venous output and arterial perfusion. J Vasc Surg 2012; 55: Mosti G, Picerni P, Partsch H. Compression stockings with moderate pressure are able to reduce chronic leg oedema. Phlebology 2012; 27: Damstra RJ, Partsch H. Compression therapy in breast cancerrelated lymphedema: a randomized, controlled comparative study of relation between volume and interface pressure changes. J Vasc Surg 2009; 49: Partsch H, Damstra RJ, Mosti G. Dose finding for an optimal compression pressure to reduce chronic edema of the extremities. Int Angiol 2011; 30:

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Int Angiol 2010; 29: Uhl JF, Benigni JP, Cornu-Thenard A et al. Relationship between medical compression and intramuscular pressure as an explanation of a compression paradox. Phlebology 2015; 30: Arfvidsson B, Eklof B, Balfour J. Iliofemoral venous pressure correlates with intraabdominal pressure in morbidly obese patients. Vasc Endovascular Surg 2005; 39: O Donnell TF Jr, Rosenthal DA, Callow AD, Ledig BL. Effect of elastic compression on venous hemodynamics in postphlebitic limbs. JAMA 1979; 242: Partsch H. Improving the venous pumping function in chronic venous insufficiency by compression as dependent on pressure and material. Vasa 1984; 13: Partsch B, Mayer W, Partsch H. Improvement of ambulatory venous hypertension by narrowing of the femoral vein in congenital absence of venous valves. Phlebology 1992; 7: Mosti G, Mattaliano V, Partsch H. Inelastic compression increases venous ejection fraction more than elastic bandages in patients with superficial venous reflux. Phlebology 2008; 23: Luetolf O, Bull RH, Bates DO, Mortimer PS. Capillary underperfusion in chronic venous insufficiency: a cause for leg ulceration? Br J Dermatol 1993; 128: Bollinger A, Fagrell B. Clinical Capillaroscopy. Toronto, Lewiston, Bern, G ottingen, Stuttgart: Hofgrefe & Huber Publications, Chen AH, Frangos SG, Kilaru S, Sumpio BE. Intermittent pneumatic compression devices physiological mechanisms of action. Eur J Vasc Endovasc Surg 2001; 21: Beidler SK, Douillet CD, Berndt DF et al. Inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy. J Vasc Surg 2009; 49: Beidler SK, Douillet CD, Berndt DF et al. Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Repair Regen 2008; 16: Eliska O, Eliskova M. Morphology of lymphatics in human venous crural ulcers with lipodermatosclerosis. 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11 Compression for leg wounds, H. Partsch and P. Mortimer Partsch H, Damstra RJ, Tazelaar DJ et al. Multicentre, randomised controlled trial of four-layer bandaging versus short-stretch bandaging in the treatment of venous leg ulcers. Vasa 2001; 30: Nelson EA, Harrison MB; Canadian Bandage Trial Team. Different context, different results: venous ulcer healing and the use of two high-compression technologies. J Clin Nurs 2014; 23: Wong IK, Andriessen A, Charles HE et al. Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers. J Eur Acad Dermatol Venereol 2012; 26: Mosti G, Crespi A, Mattaliano V. Comparison between a new, two-component compression system with zinc paste bandages for leg ulcer healing: a prospective, multicenter, randomized, controlled trial monitoring sub-bandage pressures. Wounds 2011; 23: Iglesias CP, Nelson EA, Cullum N, Torgerson DJ; VenUS I Collaborators. Economic analysis of VenUS I, a randomized trial of two bandages for treating venous leg ulcers. Br J Surg 2004; 91: H. Partsch, After studying medicine in Vienna, Freiburg and Kiel, Hugo Partsch began work in a district hospital and then at Wilhelminen Hospital in Vienna, earning the degree of General Practitioner. Thereafter he specialized in Dermatology and was appointed Professor of Dermatology at the Medical University of Vienna; he established an outpatient department for vascular diseases at Hanusch Hospital in Vienna and then served as Head of the Dermatology Department of Wilhelminen Hospital for 15 years. His main interest is peripheral vascular diseases and his scientific research publications focus on compression therapy and on the diagnosis and management of acute and chronic venous disease, vascular malformations, leg and foot ulcers and lymphoedema. H. Partsch is Honorary President of the International Union of Phlebology and Honorary Member of several international medical societies. In 2005 he created the International Compression Club (ICC), which is a forum linking medical experts with manufacturer s representatives, with the aim to promote the science behind compression therapy, to propose research trials and to organize consensus meetings on several practically important issues such as classification of compression material or evidence-based indications for compression treatment. P. Mortimer, Professor Peter Mortimer trained in Dermatology in Sheffield and Oxford. He was appointed Physician to the Skin Department at St George s and consultant skin physician to the Royal Marsden Hospital since 1986 and has been Professor of Dermatological Medicine to the University of London since Interest in lymphatics began in Oxford where he undertook his thesis on the measurement of skin lymph flow. Current research is focused on breast cancer related lymphoedema, the genetic basis of primary lymphoedema and lipoedema as well as melanoma spread by lymphatics. He has over 240 publications cited on PubMed. He has been Chief Investigator on research programme grants from The Wellcome Trust, British Heart Foundation and Cancer Research UK. His clinical practice deals almost entirely with chronic oedema, lymphoedema, lymphatic malformations, lymph-related disorders and lipoedema. He is a founder of both the Lymphoedema Support Network and British Lymphology Society and appointed the first Clinical Training Fellow in Lymphovascular Medicine in the UK.