A Guide To Compression Dressings For Venous Ulcers
Clinicians should place initial orders for compression socks prior to ulcer closure as many insurance companies will not pay for compression hose if no active ulcer exists. If the patient has lower leg edema, a compression bandage may initially be needed for edema reduction prior to sock measurement. Measurement is simple but essential. It usually consists of measuring the lower leg length and calf and ankle circumference. Customized fit stockings may be necessary for some patients. Some medical supply stores have a compression specialist on staff. However, this service seems to be less frequently available. Prescriptions for compression stockings from medical supply stores should include not only compression strength but patient measurements as well.
One would prescribe compression strength according to the severity of disease. Graduated compression of 30 to 40 mmHg at the ankle is recommended for chronic venous insufficiency and prevention of ulcer recurrence. It is important to mention that current stocking classifications are not standardized. In other words, a “class II” sock may represent 20 to 30 mmHg for one manufacturing company and 30 to 40 mmHg for another. Labels such as mild, moderate, firm and strong may also represent different strengths between companies.
Many insurance agencies will only pay for 30 to 40 mmHg stockings. Since compression hose needs to be replaced at least yearly, if not every three to six months, the patient cost can be high, especially when the socks are not reimbursed. Patients are often tempted to look for cheaper alternatives via mail order or online catalogues. However, one must encourage patients to be cautious regarding these entities as compression gradients may not be validated or even specified, there may be fewer options in size available, and the quality of the material may not be as durable. Reputable medical supply companies will take orders, bill insurances and deliver to the patient. Most will provide doctors’ offices with special order forms to facilitate the process.
Several companies make two-layer compression socks with the two layers intended to be worn together to achieve the prescribed compression. Many patients find the two layer systems easier to apply than the single layer socks. When using compression stockings, patients should receive instruction that it is best to shower in the evening and then don their socks first thing in the morning before edema has a chance to accumulate in the limb. It is important to emphasize to patients that “first thing in the morning” means before getting out of bed, not after breakfast or the morning news.
Clinicians may employ compression stockings for the treatment of smaller ulcers with manageable drainage instead of multi-layer bandages. Dual layer socks are often less disruptive over an ulcer dressing.36
One of the factors contributing to poor stocking compliance is application difficulty. Venous ulcer prevalence increases with age. Compounding this situation are the realities that comorbidities of musculoskeletal problems, neurological problems, fragility and lack of significant other assistance also increase with age.5 Although assistive donning devices are available, they are generally not covered by insurance carriers. Having a clinic assortment of application aids can help determine which would be most helpful.
Anti-embolic stockings are not appropriate for treating chronic venous disease. These stockings are made for patients who are non-ambulatory, non-mobile or bedridden to prevent venous thrombus. They have a very low graduated compression, typically only 8 to 18 mmHg, which cannot overcome the high pressures associated with ambulatory venous hypertension.37 They are not intended for long-term use and lose their elasticity over a couple of weeks.