If in doubt, use compression

Science meets practice – this was the motto of the 66th annual conference of the German Society of Phlebology and Lymphology (DGPL) in Freiburg. Bauerfeind’s symposium with the title “If in doubt, use compression” also had a practical focus. It presented the new aspects of the S2k Guidelines for Diagnosing and Treating Venous Leg Ulcers, highlighted the meaning of the Guidelines during care, and provided information about opportunities offered by compression therapy in cases of inflammatory dermatoses and contraindications.

Prof. Dr. Markus Stücker, Managing Director of the Clinic of Dermatology, Venerology, and Allergology at Ruhr University Bochum, started the symposium. He emphasized that, according to the new Guidelines for Treating Venous Leg Ulcers, compression therapy should be implemented immediately when this diagnosis is even suspected.When choosing the type of compression product, a distinction must be made between the decongestion phase and the maintenance phase. During the decongestion phase, phlebological compression bandages or medical adaptive compression systems (MAC) should be used. Intermittent pneumatic compression should only be used as an additional method when required, e.g. in patients suffering from venous leg ulcers that are hard to treat or suffering from therapy-resistant edema that cannot be sufficiently treated using the compression products mentioned previously.

When compression products are applied in practice, the new Guidelines demand they remain donned for 24 hours. Patients pursuing relevant self-management are exempt from this rule. After the decongestion phase, bandages should be replaced with specific two-layer compression stockings for venous leg ulcers. If the venous leg ulcer is painful, pain therapy can initially be carried out in addition to the compression therapy. 

If required, patients should undergo invasive varicose vein treatment early, i.e. during the first two weeks. Even after the venous leg ulcer has healed, continued wearing of compression products should be recommended to patients, with Class 1 knee-length compression stockings usually being sufficient. Lastly, patients’ skin care must not be neglected when wearing compression products. Patients should be advised that the relevant care products are not harmful to compression bandages or stockings.

Care compliant with the Guidelines

Kerstin Protz, renowned expert in care and wound treatment, highlighted the urgency for specialists to become familiar with the new Guidelines and to implement them in their practical everyday work. According to the new Guidelines, padding on the inside and outside should be applied when compression bandaging is donned.

Wound treatment should be based on the indication and not cause pain, according to the new Guidelines. This includes expert cleaning as well as exudate and infection management. For mechanical cleaning, sterile (fleece) dressings are recommended, and for the care of dry skin, lipophilic skin products with moisture-retaining factors, such as urea. Her tip for patients with high volumes of exudate during decongestion phases and severe pain when dressings are changed: use siliconized transfer foam dressings that do not adhere to the base of the wound but that drain the exudate vertically and can therefore stay in situ for up to a week. The secondary dressing, e.g. the super absorber, needs to be replaced more often when it has reached its capacity. Kerstin Protz recommends using fine-pored polyurethane foam dressings during the maintenance phase, with a silicone coating if required. In order not to cause further damage to the skin, dressings with polyacrylate adhesive should be avoided.

Compression therapy in cases of infections and inflammatory dermatoses

Dr. Jürg Traber, Senior Physician at Bellevue Vein Hospital in Kreuzlingen (Switzerland), pointed out that there are currently no evidence-based studies substantiating that, in cases of an infection in a lower extremity, donning of a compression product would cause the infection to shift from the lower leg to the thigh, for example. He also highlighted that conditions induced by compression products occur rarely to very rarely (1< 10,000)[1]. This means that there is no evidence of compression products generally increasing the risk of infection.

Using another study as an example, Dr. Jürg Traber explained^[2] that compression therapy does not lead to a deterioration in cases of inflammatory dermatoses. He therefore does not believe that compression should be contraindicated in cases of infectious inflammatory dermatoses. In addition, Dr. Jürg Traber referred to a study^[3] which substantiated that test subjects using compression following infections of the soft tissue suffered from recurring cellulitis much less frequently than test subjects who were not using compression products. The relevant cytokines were also significantly reduced after compression use.

In cases of severe local wound and tissue infection, compression use can be personalized. This fact is also mentioned in the new Guidelines with regard to inflammatory dermatoses in the legs. Referring to further studies[4],[5] Dr. Jürg Traber pointed out that many inflammatory dermatoses in the legs, with or without concomitant edema, are an indication for the use of compression therapy. The Guidelines also recommend this. Compression therapy is therefore not deemed as “off-label use”, but compression products promote successful outcomes when treating infectious and non-infectious inflammation.

[1] Rabe E, Partsch H, Morrison N, Meissner MH, Mosti G, Lattimer CR, Carpentier PH, Gaillard S, Jünger M, Urbanek T, Hafner J, Patel M, Wu S, Caprini J, Lurie F, Hirsch T. Risks and contraindications of medical compression treatment – A critical reappraisal. An international consensus statement. Phlebology. 2020 Aug;35(7):447-460. doi: 10.1177/0268355520909066.

[2] Eder, S., Stücker, M., Läuchli, S.et al.Ist die Kompressionstherapie bei Erysipel des Unterschenkels kontraindiziert?. Hautarzt 72, 34–41 (2021). doi: 10.1007/s00105-020-04682-4.

[3] Webb E, Neeman T, Bowden FJ, Gaida J, Mumford V, Bissett B. Compression Therapy to Prevent Recurrent Cellulitis of the Leg. N Engl J Med. 2020 Aug 13;383(7):630-639. doi: 10.1056/NEJMoa1917197. PMID: 32786188.

[4] Dissemond J, Protz K, Stücker M. [Kompressionstherapie in der Dermatologie]. J Dtsch Dermatol Ges. 2023 Sep;21(9):1003-1020. German. doi: 10.1111/ddg.15161_g. PMID: 37700410.

[5] Dissemond, J; Assenheimer, B; Gerber, V; Kurz, P; Läuchli, S; Panfil, E-M; Probst, S; Traber, J; Strohal, R

Lokaltherapie chronischer Wunden: Das M.O.I.S.T. Konzept. DMW – Deutsche Medizinische Wochenschrift 2023; 148(07): 400 – 405 doi: 10.1055/a-1987-4999.

When is compression therapy actually contraindicated?

Dr. Tobias Hirsch, with his own practice for Internal Medicine and Vascular Diseases in Halle, subsequently clarified whether and in which patients compression therapy is contraindicated. He referred to current study results² and presented examples of a patient with cardiac insufficiency as well as a patient suffering from peripheral arterial disease (PAD) and polyneuropathy. His conclusion: compression therapy is not contraindicated for Stage NYHA I and II cardiac insufficiency in patients suffering form lymphedema. But the affected patients have to be examined carefully, and the particular complexity of cardiac insufficiency must be considered during treatment. While patients with Stage NYHA III cardiac insufficiency can undergo compression therapy, patients with Stage NYHA IV cardiac insufficiency, on the other hand, are excluded from compression therapy.

In PAD patients, the arterial circulation must first be checked before compression therapy can be started. In most cases, feeling the vein pulse is sufficient, in the area of the foot, for example. For patients with an ankle-brachial index greater than 0.5 and absolute arterial pressure at the ankle of 60 mmHg, non-elastic compression with a contact pressure of up to 40 mmHg is not considered to be problematic^[1].

However, compression therapy is contraindicated for patients suffering from neuropathy. Because of their lack of pain perception, they often cannot tell whether the compression product has been donned correctly or will lead to constriction or skin irritation, for example. If compression has to form part of the treatment nevertheless, the patient must be monitored carefully. The correct fit and appropriate material must be guaranteed. In these cases, flat knit products are recommended because of the higher stiffness of this type of knitted fabric.

[1] Reich-Schupke und Stücker, Fachbuch „Moderne Kompressionstherapie“, Köln 2013

Source:

Bauerfeind corporate symposium “If in doubt, use compression” on the occasion of the 66th annual conference of the German Society of Phlebology and Lymphology (DGPL) in Freiburg, Breisgau, October 4, 2024.

Pictures: Thomas Hauss, Bauerfeind AG