Necessary care of the lower limb

Compression hosiery is primarily used to prevent venous ulceration because it improves blood circulation and reduces venous pressure in the legs.

Venous ulcers are caused by chronic venous insufficiency, where the veins in the legs struggle to pump blood back to the heart effectively.

This leads to increased pressure in the veins (venous hypertension) and poor blood flow, which can cause damage to the skin and surrounding tissue, eventually leading to ulcers. Compression therapy works by:

1. Improving venous return: Compression stockings apply graduated pressure, which is stronger at the ankle and gradually decreases up the leg. This pressure helps push blood from the lower legs back toward the heart, improving circulation and reducing blood pooling in the veins.
2. Reducing venous pressure: By promoting better blood flow and reducing the volume of blood that stagnates in the veins, compression stockings lower the pressure inside the veins. This helps prevent damage to the blood vessels and tissues, reducing the risk of ulcer formation.
3. Enhancing the calf-muscle pump: The calf muscles act as a pump to help move blood through the veins. Compression stockings support this function by improving the efficiency of the calf-muscle pump, further aiding venous return.
4. Preventing skin breakdown: Poor circulation can lead to swelling, skin damage, and inflammation, which increases the likelihood of ulcers. Compression helps minimise oedema and helps prevent the skin from breaking down.

By addressing the underlying causes of venous hypertension and poor circulation, compression hosiery plays a crucial role in preventing venous ulcers and improving overall leg health.

Following guidance from the NWCS on immediate and necessary care, compression stockings should apply mild graduated compression, of 20mmHg or less at the ankle. This would be equivalent to British Standard Class 1 hosiery:

• Class 1 (mild compression): 14–17 mmHg
• Class 2 (moderate compression): 18–24 mmHg
• Class 3 (strong compression): 25–35 mmHg. 

Read the Best practice statement on Compression hosiery: A patient-centric approach (Wounds UK 2021).

The practitioner needs to check that the patient has an appropriate limb shape to wear a mild compression stocking. It is important to check for a normal limb profile, where the ankle circumference is smaller than the calf circumference.

The material of a British Standard Class one stocking is thin and elastic, with low stiffness. These stockings are not designed to support large amounts of swelling and if used in this instance, they are likely to create further problems.

Deep pitting oedema, skin folds, or irregular limb shape may indicate that the patient is not suitable for mild compression, and they should be referred for further assessment.

Offer first-line mild graduated compression to patients who have no red flag symptoms or conditions, intact sensation, a normal leg profile and a low risk of pressure damage over bony prominences.

Do not offer compression to patients with red flags. Refer them urgently for treatment, as recommended by the NWCS. 

For British Standard Class 1 stockings you generally need two measurements as a minimum: the widest part of the calf and just above the ankle bone. Always check the company requirements, as these can vary.

Patients should be prescribed a minimum of two pairs of medical British Standard Class 1 compression hosiery (one to wear and one to wash), every three months, to ensure the effectiveness of the compression.

This medi UK video will show you how to measure and fit British Standard duo med soft compression hosiery.  

Image and video used with permission from medi UK.  

It is important to ensure the patient, or their carer/family, can apply the hosiery. There are a variety of donning and doffing aids that are available on prescription.

Wearing rubber gloves with soft interior linings can aid grip during application and removal of all types of compression stockings.

Video resources (YouTube)

• Accelerate: Demonstrating different donning and doffing aids for compression hosiery. This video demonstrates various tools and techniques to guide the application and removal of compression garments, enhancing patient and clinician comfort and independence.

• Accelerate: Optimising compression - the use of Class 1 hosiery for early intervention. This video explains how using mild compression for a new wound, skin tear or laceration on the lower limb can help prevent deterioration and support healing. 

Onward referrals should be considered when further assessment or specialist expertise is needed. Local guidance should outline the appropriate circumstances for referral and specify the relevant services or professionals. 

Examples include:

• local leg ulcer clinic/community leg club
• vascular specialist for diagnosis of venous disease and/or arterial disease and possible vascular intervention
• lymphoedema specialist
• dermatology
• tissue viability nurse
• 14-day holistic assessment. 

Patient education is key to ensuring effective use of compression therapy. Clear, straightforward guidance should be provided to help patients understand how to use their treatment confidently, such as:

• Get used to the compression hosiery gradually by wearing it for short periods—the hosiery should never feel uncomfortable or painful to wear; however, patients may notice a feeling of compression or squeeze when they are worn.
• The stocking should lie evenly and smoothly without creases. It should not be rolled over at the top, as this will affect the compression and may cause skin damage.
• Patients should be prescribed two pairs at a time and be replaced every three months.
• Hosiery should be washed by hand or on a gentle machine wash (depending on the manufacturer’s instructions). Do not use fabric conditioner, dry on a radiator or tumble dry, as this may damage the compression fibres and reduce effectiveness.  
• Advice on daily wear time, skin care and how to monitor for discomfort or changes (for example, increased pain, tightness or new symptoms).

Once compression therapy has started, be alert to red flag symptoms that may indicate complications or require urgent referral. These include:

• clinical signs of infection, such as increased exudate, malodour, erythema or swelling around the wound – the patient may feel generally unwell with pyrexia
• increased pain or swelling in the affected limb
• altered sensation or numbness in the limb
• persistent skin changes or discolouration to the leg or toes (skin colour should return to normal within 15 minutes of removing stockings).

If any red flag signs or symptoms are identified whilst the patient is wearing compression hosiery, follow your local referral pathway immediately.