Wound, Ostomy and Continence Nurses Society™

Compression for Primary Prevention, Treatment and Prevention of  Recurrence of

Venous Leg Ulcers

An Evidence- and Consensus-based Algorithm for Care Across the Continuum

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An Evidence- and Consensus-based Algorithm

Compression therapy is the cornerstone of treatment for CVI. Compression has been shown to improve healing rates in patients with existing venous leg ulcers (VLU) and reduce the likelihood of VLU recurrence. In an effort to customize compression therapy for each individual with CVI, the Wound, Ostomy and Continence Nurses Society™ (WOCN®) set out to develop an evidence- and consensus-based algorithm on Compression for Primary Prevention, Treatment and Prevention of Recurrence of Venous Leg Ulcers. To learn more about the algorithm's development, view the accompanying Journal of Wound, Ostomy and Continence Nursing article.

The electronic version of the algorithm will guide you through a series of assessments. Click on the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box.

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Click the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box. A hand icon will guide you to the next step in the algorithm. You cannot proceed until the hand disappears.

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Clinical Assessment of Lower Extremities

health history icon

Health History

  • triggers (e.g., injury to leg, cellulitis, dry skin with itching, etc.)
  • risk factors (e.g., family history, previous deep vein thrombosis, surgery/trauma to leg, etc.)
  • comorbid conditions (e.g., obesity, impairment of calf muscle pump, varicose veins, sickle cell disease, etc.)

Physical assessment:

Examination of both lower extremities noting condition of the skin, hemosiderosis, ankle range of motion and calf muscle strength, functional mobility, extent and location of edema, superficial vascular changes, presence of any wounds, capillary refill < 2 seconds and palpation of pulses.

Obtain appropriate studies such as Ankle Brachial Index (ABI)/Ankle Brachial Pressure Index (ABPI) to exclude significant arterial disease. Refer to ABI Quick Reference Guide for Clinicians and ABI Value Table.

Conduct differential diagnosis (Refer to LEVD Appendices C: Differences between Edema, Lymphedema, & Lipedema and D: Venous Eczema and Cellulitis located in WOCN Society Guideline for Lower-Extremity Venous Disease [2011]) Refer to WOCN Society’s Quick Reference Guide for Lower-Extremity Wounds: Venous, Arterial, and Neuropathic (2013)

What do your findings indicate?

Chronic venous insufficiency

Disease or wound of other etiology (e.g., lymphedema, lipedema, arterial, or neuropathic)

Refer to WOCN Society’s Quick Reference Guide for Lower-Extremity Wounds: Venous, Arterial, and Neuropathic

Refer to CEAP table to determine severity of chronic venous insufficiency

No wound (CEAP 1-4) or healed wound (CEAP 5)

Active wound (CEAP 6)

No visible or palpable signs of venous disease (CEAP 0)

Proceed to the CEAP 1-2 pathway

Proceed to the CEAP 3-4 pathway

Proceed to the CEAP 5 pathway

Educate patient and family about lifestyle factors that promote leg health including

  • effects of smoking, advise smoking cessation
  • following healthy nutrition practices such as weight management
  • avoiding mechanical trauma to leg
  • avoiding crossing legs, prolonged sitting or standing
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • avoiding wearing high heels.

Manage Signs/Symptoms per Facility Protocol OR Clinical Guideline

Here is your result

Patient should be reassessed at least annually to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).

Test again

Determine need for compression based on symptoms (i.e., burning, itching, heaviness, aching, or pain)

Compression is needed
Compression is not needed

Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.

Refer to Tables:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.

Evidence of prior deep vein thrombosis
No evidence of prior deep vein thrombosis

Educate patient and family/caregiver about:

  • effects of smoking, advise smoking cessation
  • avoiding mechanical trauma to leg
  • avoiding prolonged sitting or standing
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • extremity elevation
  • prevention of trauma
  • appropriate footwear (e.g., avoid high heels)
  • nutrition, weight management
  • use of non-sensitizing emollients to prevent dermatitis

Here is your result

Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).

Test again

Use compression stockings or devices at a level of 30-40 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.  

When measuring for compression stockings or devices, use standardized methods based on manufacturer’s recommendations.

Educate patient and family/caregiver about:

  • effects of smoking, advise smoking cessation
  • avoiding mechanical trauma to leg
  • avoiding prolonged sitting or standing
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • extremity elevation
  • prevention of trauma
  • appropriate footwear (e.g., avoid high heels)
  • nutrition, weight management
  • use of non-sensitizing emollients to prevent dermatitis
  • use of compression stockings/devices

Use compression stockings or devices at a level of 20-30 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.

Refer to ABI/ABPI

If ABI/ABPI ≥ 0.8 and ≤ 1.3 proceed to compression.

In patients with mixed venous and arterial disease (ABI/ABPI 0.5 to 0.8) consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.

If ABI/ABPI < 0.5 or > 1.3, do not use compression.

Initiate referral for evaluation and management of significant arterial disease.

Educate patient and family/caregiver about:

  • effects of smoking, advise smoking cessation
  • avoiding mechanical trauma to leg
  • avoiding leg elevation
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • appropriate footwear
  • nutrition, weight management
  • use of non-sensitizing emollients to prevent dermatitis
  • use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Here is your result

Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).

Test again

Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.

Refer to Tables:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.

Evidence of prior deep vein thrombosis
No evidence of prior deep vein thrombosis

Use compression stockings or devices at a level of 30-40 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.

Use compression stockings or devices at a level of 20-30 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.

When measuring for compression stockings or devices, use standardized methods based on manufacturer’s recommendations.

Educate patient and family/caregiver about:

  • effects of smoking, advise smoking cessation
  • avoiding mechanical trauma to leg
  • avoiding prolonged sitting or standing
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • extremity elevation
  • prevention of trauma
  • appropriate footwear (e.g. avoid high heels)
  • nutrition, weight management
  • use of non-sensitizing emollients to prevent dermatitis
  • use of compression stockings/devices
  • use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.

Here is your result

Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).

Test again

Refer to ABI/ABPI

If ABI/ABPI ≥ 0.8 and ≤ 1.3 proceed to compression.

In patients with mixed venous and arterial disease (ABI/ABPI 0.5 to 0.8) consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.

If ABI/ABPI < 0.5 or > 1.3, do not use compression.

Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.

Refer to Tables:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.

Consider use of pentoxifylline (Trental) to enhance microcirculation and prevent recurrence. (Refer to Pharmaceuticals Table)

Educate patient and family/caregiver about:

  • effects of smoking, advise smoking cessation
  • avoiding mechanical trauma to leg
  • avoiding prolonged sitting or standing
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • extremity elevation
  • appropriate footwear (e.g. avoid high heels)
  • nutrition, weight management
  • use of non-sensitizing emollients to prevent dermatitis
  • use of lifelong compression stockings/devices
  • use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.

Here is your result

Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).

Test again

Initiate referral for evaluation and management of significant arterial disease.

Educate patient and family/caregiver about:

  • effects of smoking, advise smoking cessation
  • avoiding mechanical trauma to leg
  • extremity elevation
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • appropriate footwear
  • nutrition, weight management
  • use of non-sensitizing emollients to prevent dermatitis
  • use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Here is your result

Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).

Test again

Consider principles of wound bed preparation prior to selection of topical therapy.

Apply emollients to intact skin underneath compression to prevent occurrence of dermatitis.

Refer to ABI/ABPI

If ABI/ABPI < 0.5 or > 1.3, do not use compression.

In patients with mixed venous and arterial disease (ABI 0.5 to 0.8), consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.

If ABI ≥ 0.8 or greater, proceed to compression.

Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.

Refer to Tables:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.

Initiate referral for evaluation and management of significant arterial disease.

Educate patient and family/caregiver about:

  • effects of smoking, advise smoking cessation
  • avoiding mechanical trauma to leg
  • avoiding leg elevation
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • appropriate footwear
  • wound care management
  • nutrition, weight management
  • use of non-sensitizing emollients to prevent dermatitis
  • use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

Here is your result

Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).

Test again

Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.

Educate patient and family about:

  • effects of smoking, advise smoking cessation
  • avoiding mechanical trauma to leg
  • avoiding prolonged sitting or standing
  • exercising and participating in physical activity often (consider referral to physical therapist for specific home exercise program)
  • extremity elevation
  • appropriate footwear (e.g. avoid high heels)
  • nutrition, weight management
  • use of non-sensitizing emollients to prevent dermatitis
  • use of lifelong compression stockings/devices
  • wound care and compression management
  • use of pharmaceuticals (horse chestnut seed oil, pentoxifylline [Trental]) if applicable (Refer to Pharmaceuticals Table)

If the wound fails to improve or deteriorates, evaluate for barriers to healing.

If treatment is effective, continue current therapy until healed

Here is your result

Proceed to the CEAP 5 section of the algorithm.

Test again

Refer for advanced adjuvant therapies and/or consider referral for evaluation and management of significant arterial disease. Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.

Here is your result

Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).

Test again

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Pharmaceuticals Table

Pharmaceuticals Uses Dose Reference
Horse chestnut seed extract Reduce symptoms of CVI such as leg pain, fatigue/tiredness, leg swelling 300 mg of horse chestnut seed extract containing 50 mg of the active ingredient, aescin, twice daily. Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012 Nov 14
Pentoxifylline (Trental) Hemorheologic agent enhances microcirculatory blood flow and may be used in CVI patients in conjunction with compression therapy 400 mg ORALLY 3 times per day with food Jull AB, Arroll B, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD001733. DOI: 10.1002/14651858.CD001733.pub3.
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ABI Table

ABI Perfusion Status
> 1.3 Elevated, incompressible vessels
> 1.0 Normal
≤ 0.9 LEAD
≤ 0.6 to 0.8 Borderline
≤ 0.5 Severe ischemia
≤ 0.4 Critical ischemia, limb threatened

J Wound Ostomy Continence Nurs. 2012;39(2S):S21-S29.

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Compression Therapies

Type of Compression Examples Performance Characteristics and mmHg Pressure
Light Support Crepe, rolled gauze Holds dressings in place
No significant compression
Light Compression, support (elastic) Elastocrepe (BSN medical), Tubigrip (Mölnlycke), Medigrip (Medline) Low pressure, light support
14-17 mmHg
Cohesive bandage Coban (3M), Co-flex (Andover), Medi-Rip (Hartmann), Sensi-wrap (Dynarex) Self-adherent, compression well sustained
High elastic compression Tensopress (BSN Medical), Setopress (Mölnlycke), SurePress (Medline) Sustained compression, wash and reuse
25-40 mmHg
Multilayer high compression 3 or 4 layer Profore (Smith & Nephew), Comprifore (BSN medical), Dynaflex (Systagenix), FourPress (Hartmann), Fourflex (Medline) To maintain 35-40 mmHg at the ankle
Inelastic Compression Short-stretch - Comprilan (BSN medical), Coban 2 (3M), Rosidal K (Lohmann & Rauscher), Farrow Wrap (Farrow Medical)

Unna’s boot paste- Gelocast (BSN medical),
Primer (DermaSciences)
Duke boot


CircAid legging (mediUSA)
23-40 mmHg


20-30 mmHg light;
30-40 mmHg regular
Zinc oxide impregnated bandage often with calamine (plus cohesive bandage)

Static compression device
Inelastic Compression
Short-stretch - Comprilan (BSN medical), Coban 2 (3M), Rosidal K (Lohmann & Rauscher), Farrow Wrap (Farrow Medical)23-40 mmHg
Unna’s boot paste- Gelocast (BSN medical),
Primer (DermaSciences)
Duke boot
20-30 mmHg light;
30-40 mmHg regular
Zinc oxide impregnated bandage often with calamine (plus cohesive bandage)
CircAid legging (mediUSA) Static compression device

Table compiled from information in:
O’Meara, S., Cullum, N.A., & Nelson, E.A. (2009). Compression for venous leg ulcers. Cochrane Database Syst Rev (1), CD000265.

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Compression Stocking Classifications

U.S. Class Descriptor Ankle Pressure Indication
Class 1 Light support 20-30 mmHg Treatment of varicose veins
Class 2 Medium support 30-40 mmHg Treatment of more severe varicosities and prevention of leg ulcers
Class 3 Strong support 40-50 mmHg Treatment of severe chronic venous hypertension and severe varicose veins, and to prevent leg ulcers
U.K. Class Descriptor Ankle Pressure Indication
Class 1 Light support 14–17 mmHg Treatment of varicose veins
Class 2 Medium support 18-24 mmHg Treatment of severe chronic venous hypertension and severe varicose veins, and to prevent venous leg ulcers in patients with thin legs
Class 3 Strong support 25-35 mmHg Used to treat more severe varicosities and to prevent venous leg ulcers

Adapted from: O’Meara, S., Cullum, N.A., & Nelson, E.A. (2009). Compression for venous leg ulcers. Cochrane Database Syst Rev (1), CD000265; Partsch, H., Clark, M., Mosti, G., et al. (2008). Classification of compression bandages: Practical aspects. Dermatologic Surgery, 34(5), 600-609.

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Formulary of Compression Therapy Products

Category Type Examples *
Wraps Multilayer



Long stretch

Short stretch

Paste**
Profore (Smith & Nephew),
Comprifore (BSN Medical),
Dyna-Flex (Systagenix)

ACE bandage (3M)

Comprilan (BSN Medical), Setopress (Mölnlycke)

Gelocast (BSN Medical), Viscopaste (Smith & Nephew), Primer (Derma Sciences)
Garments Reusable inelastic device

Tubular sleeve

Stockings
CircAid (mediUSA)


Tubigrip (Mölnlycke)
Medigrip (Medline)

Jobst (BSN Medical)
Mediven (mediUSA)
Juzo (Juzo USA)
Garments
Reusable inelastic deviceCircAid (mediUSA)
Tubular sleeve
Tubigrip (Mölnlycke)
Medigrip (Medline)
StockingsJobst (BSN Medical)
Mediven (mediUSA)
Juzo (Juzo USA)
Intermittent Pneumatic Compression Pumps   Tactile Systems Technology
Lympha Press
Bio Compression Systems, Inc.

**Use with cohesive bandage

*Not all inclusive

Adapted with permission from Carmel, J. E. (2012). Venous ulcers. In R. A. Bryant & D. P. Nix (Eds.) Acute & chronic wounds: Current management concepts (4th ed.). St. Louis, MO: Elsevier.

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Clinical Classification of CVI Using
The CEAP Classification
(Clinical, Etiology, Anatomy, Pathophysiology)

Class Clinical Signs
0 No visible or palpable signs of venous disease picture of No visible or palpable signs of venous disease
1 Teleangiectases, reticular veins, malleolar flare picture of Teleangiectases, reticular veins, malleolar flare
2 Varicose veins, distinguished from reticular veins by a diameter of 3 mm or more picture of Varicose veins, distinguished from reticular veins by a diameter of 3 mm or more
3 Edema without skin changes picture of Edema without skin changes
4 Skin changes ascribed to venous disease
  4a – hyperpigmentation  4c – lipodermatosclerosis
  4b – venous eczema     4d – atrophie blanche
picture of Skin changes ascribed to venous disease
5 Skin changes (as defined above) in conjunction with healed ulceration picture of Skin changes in conjunction with healed ulceration
6 Skin changes (as defined above) in conjunction with active ulceration picture of Skin changes in conjunction with active ulceration
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Special Considerations Table

Special Considerations
All Patients
  • Use standardized methods when measuring for compression stockings
  • Apply compression wraps from metatarsal head to tibial tubercle, including the heel
  • Assess and monitor pain and circulatory status while using compression
Patient/Caregiver with functional limitations
  • Use donning/doffing devices
  • Use alternative compression device (not a stocking)
  • Use compression wraps ongoing
  • Refer to rehabilitation services to address limitations
Patient with atypical shape/size leg
  • Use modified compression
  • Refer to a qualified fitter for custom stockings or garment
  • Use intermittent pneumatic compression device
Patient with limited financial resources
  • Use reusable wrap products
  • Use reusable garments
  • Use intermittent pneumatic compression device
Non-ambulatory or bedbound patients
  • Use elastic bandages
Patients unable to tolerate 30-40 mmHg compression
  • Use lower level of compression to enhance adherence
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Critical thinking point:

While it may be true that a patient has a Braden score of less than 18 and a pressure ulcer on the trunk or pelvis, it may not be necessary for them to have a different level of support surface. There are some factors that cannot be reflected on an algorithm and while few, they exist. At those moments, a skilled clinical assessment with critical thinking/decision making is required.

For example, a patient may have a Braden score of 17 and a Stage I or II on their sacrum or trunk but are able to turn side to side so would be able to stay on their current surface. However, if they have a medical condition that prohibits turning to one side (e.g., SOB, cardiac rhythm changes, device in place, etc.), they would need to be moved to a higher-level support surface because they have only one available turning surface.