Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Compression treatment improves healing in venous leg ulcers

ACP J Club. 1998 Sep-Oct;129:36. doi:10.7326/ACPJC-1998-129-2-036


Source Citation

Cullum N, Fletcher AW, Nelson EA, Sheldon TA. Compression bandages and stockings in the treatment of venous leg ulcers. In: The Cochrane Library, Issue 1, 1998. Oxford: Update Software.


Abstract

Question

In patients with venous leg ulcers, do compression bandages improve healing?

Data sources

Studies were identified in 16 electronic databases, 5 journals and several conference proceedings were hand searched, bibliographies were searched, and experts were consulted.

Study selection

Randomized controlled trials (RCTs) were selected if they studied patients who had venous leg ulcers and interventions were any form of bandage or compression stockings (except intermittent pneumatic compression) and measured leg ulcer healing.

Data extraction

Data were extracted on study quality, interventions (elastic and inelastic bandages, short stretch bandages, multilayer and single-layer bandage systems, and compression hosiery), and healing.

Main results

21 RCTs were included. 3 RCTs compared compression (Unna's boot) with dressings alone; 2 found a higher proportion of healing with compression, and the third showed a nonsignificant trend toward greater healing with compression. 3 RCTs compared elastic with inelastic compression; meta-analysis showed that the rate of healing at 3 months was higher with elastic compression { P < 0.05}* (Table). 3 small RCTs found no difference between multilayer high compression (4-layer bandage) and inelastic compression (Unna's boot or short stretch bandage). 1 RCT showed higher healing rates with both 4-layer and short stretch bandages than a paste bandage and an outer support bandage. 4 RCTs evaluated multilayer, high-compression systems with single-layer systems (Setopress, Granuflex, and Porelast); meta-analysis showed a higher rate of complete healing at 12 and 24 weeks with the multilayer systems { P < 0.005}* (Table). 1 study compared Unna's boot with a single-layer bandage and found no differences. 1 RCT compared 2 compression stockings with a short stretch bandage and found that the stockings were associated with a higher rate of complete healing at 3 months. Cost data were insufficient to analyze.

Conclusions

Compression treatment improves healing of venous leg ulcers better than no compression. High compression is more effective than low compression, and multilayer systems are more effective than single-layer systems.

Sources of funding: Department of Health Studies, University of York; Department of Medicine, University of Liverpool; National Health Service Technology Assessment Programme; Department of Health and Social Services, Northern Ireland.

For article reprint: Dr. N. Cullum, Director, Centre for Evidence Based Nursing, Department of Health Studies, University of York, Genesis 6, Science Park, York YO10 5DG, England, UK. FAX 44-1904-434-103.

* P values calculated from data in article.


Table. Comparison of compression bandages in complete leg ulcer healing†

Comparison of type of bandage at ≤ 3 mo Weighted comparison RBI (95% CI) NNT (CI)
Elastic vs inelastic 58% vs 37% 54% (19 to 99) 5 (4 to 12)
Multi- vs single-layer 65% vs 46% 41% (12 to 77) 6 (4 to 14)

†Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in article.


Commentary

The systematic review by Cullum and colleagues shows that high-compression bandaging is at least twice as effective as no or low-compression treatment in complete venous ulcer healing. Multilayer compression bandaging seems to be superior to single-layer bandaging, and elastic multilayer bandaging is superior to inelastic multilayer bandaging. Wearing 2 compression stockings together is also effective.

In a western population of 1 million persons, 1000 to 3000 will have active lower leg ulceration; of these, 50% to 75% will have isolated venous disease (1-3). Many venous leg ulcers occur at sites other than over the medial malleolus (2). The treatments used vary greatly, and high compression is used in only 40% of persons who might benefit (4). Thus, the potential for improved management is great.

The trials in this review are generally small and of poor quality, and the extent of publication bias has not been assessed. Nonetheless, I recommend that older persons with below-knee ulcers ≥ 6 weeks in duration in whom arterial disease is excluded by an ankle-brachial systolic pressure ratio ≥ 0.9 (mean of 2 readings measured by hand-held Doppler ultrasonography) should receive high-compression bandaging (5, 6). The most cost-effective way of delivering this and, indeed, the optimal pressure regimen remain uncertain (7).

Ian Harvey, MB, BCh, PhD
University of East AngliaNorwich, England, UK


References

1. Baker SR, Stacey MC, Jopp-McKay AG, Hoskin SE, Thompson PJ. Epidemiology of chronic venous ulcers. Br J Surg. 1991;78:864-7.

2. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Chronic ulcer of the leg: clinical history. BMJ. 1987;294:1389-91.

3. Nelzon O, Bergqvist D, Lindhagen A, Hallbook T. Chronic leg ulcers: an underestimated problem in primary health care among elderly patients J Epidemiol Community Health. 1991;45:184-7.

4. Freak L, Simon D, Kinsella A, et al. Health Trends. 1995;27:133-6.

5. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Arterial disease in chronic leg ulceration: an underestimated hazard? Lothian and Forth Valley leg ulcer study. BMJ. 1987;294:929-31.

6. Fowkes FG, Housley E, Macintyre CC, Prescott RJ, Ruckley CV. Variability of ankle and brachial systolic pressures in the measurement of atherosclerotic peripheral arterial disease J Epidemiol Community Health. 1988;42:128-33.

7. Phillips TJ, Dover JS. Leg ulcers. J Am Acad Dermatol. 1991;25:965-87.