Venous Leg Ulcers & Compression Therapy

1 Venous Insufficiency Cascade — Pathophysiology

Valve Incompetence

DVT / primary reflux

→

Venous Hypertension

Sustained ambulatory

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Capillary Leak

Fibrin cuffing / WBC trapping

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Lipodermatosclerosis

Woody induration

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Ulceration

Gaiter / medial ankle

CEAP Classification

C0 No visible or palpable signs of venous disease

C1 Telangiectasia / reticular veins (<3mm)

C2 Varicose veins (>3mm)

C3 Oedema — no skin changes yet

C4a Pigmentation + venous eczema

C4b Lipodermatosclerosis / atrophie blanche

C5 Healed venous ulcer

C6 Active venous ulcer — primary clinical focus

CEAP suffix: A = asymptomatic · S = symptomatic · Ep = primary · Es = secondary (post-DVT)

Risk Factors

◆ DVT history

◆ Obesity (BMI >30)

◆ Prolonged standing

◆ Pregnancy (multiparity)

◆ Family history

◆ Immobility / paralysis

◆ Previous leg ulcer

◆ Phlebitis / trauma

Characteristic Skin Signs

Lipodermatosclerosis: woody/indurated skin — "inverted champagne bottle"

Haemosiderin pigmentation: brown/rust discolouration from RBC breakdown

Venous eczema: erythema, scaling, itching, weeping periwound

Atrophie blanche: white avascular scarring — capillary obliteration

Corona phlebectatica: fan-shaped ankle intradermal veins

VLU Clinical Features

Feature	Venous (VLU)	Arterial	Diabetic/Neuropathic
Location	Gaiter area / medial ankle	Distal / toes / pressure points	Plantar / pressure points
Wound edge	Irregular, sloping	Punched-out, well-defined	Callus rim, punched-out
Wound bed	Sloughy / granulating	Necrotic / pale / eschar	Variable / deep
Exudate	Moderate to high	Low / dry	Variable
Pain	Mild–moderate; relieves on elevation	Severe; worse on elevation / rest pain	Minimal (neuropathy)

ABPI — Ankle Brachial Pressure Index

MANDATORY before applying compression therapy

Normal: 0.8 – 1.2 FULL COMPRESSION

High compression 40 mmHg — 4-layer or equivalent

Mild–Mod PAD: 0.5 – 0.79 MODIFIED

Reduced compression 15–25 mmHg with specialist input; monitor closely

Severe PAD: < 0.5 NO COMPRESSION

Urgent vascular surgery referral — limb-threatening

Calcified vessels: > 1.3 TOE PRESSURE

ABPI unreliable (diabetes/renal). Use toe-brachial index (TBI >0.6 = OK)

ABPI formula: Highest ankle systolic ÷ Highest brachial systolic. Use hand-held Doppler 8–10 MHz probe.

Structured Ulcer Assessment

SIZE & DEPTH

Measure length × width (cm²). Note depth — probe with sterile swab. Photograph at each visit for serial comparison.

WOUND BED (% tissue types)

Granulation (red/pink) · Slough (yellow) · Necrosis (black) · Epithelialising (pale pink edges)

EXUDATE

Volume (low/mod/high) · Colour (serous/serosanguinous/purulent) · Viscosity · Odour

PERIWOUND SKIN

Maceration · Excoriation · Eczema · Induration · Erythema (cellulitis?) · Pigmentation

PAIN ASSESSMENT

NRS 0–10 at rest / dressing change / with compression. Character: aching, burning, sharp?

VCSS — Venous Clinical Severity Score

10-item score (0–3 each): pain, varicosities, oedema, skin pigmentation, inflammation, induration, ulcer count, duration, size, compressibility. Max 30.

Differential Diagnosis of Leg Ulcers

Venous (70–80%)

ABPI 0.8–1.2 · gaiter · venous stigmata · high exudate · moderate pain

Arterial (10–15%)

ABPI <0.8 · absent pulses · rest pain · pale/necrotic bed · cold foot

Mixed (15–20%)

ABPI 0.5–0.79 · both ischaemic & venous features

Diabetic / Neuropathic

Plantar / pressure sites · painless · callus rim · peripheral neuropathy

Malignant (Marjolin's)

Raised/everted edges · rapidly growing · non-healing >3 months → BIOPSY

Pyoderma Gangrenosum

Violaceous undermined edge · rapid extension · systemic disease (IBD/RA) · pathergy positive

BIOPSY RULE: Biopsy any ulcer that is atypical in appearance OR fails to heal after 12 weeks of appropriate treatment to exclude malignancy and vasculitis.

Comprehensive Patient History

Medical: DVT/PE · coagulopathy · CCF · DM · RA · IBD · malignancy

Vascular: claudication · rest pain · previous surgery · IVC filter

Medication: anticoagulants · steroids · NSAIDs · diuretics

Social: occupation (standing) · BMI · smoking · alcohol · social support

Mobility: ankle ROM · calf muscle pump · walking aids · sedentary

Ulcer Hx: duration · previous episodes · treatments tried · concordance

High Compression Bandaging

First-line treatment — 40 mmHg sub-bandage pressure at ankle

4-Layer Bandage System (Profore)

Layer 1: orthopaedic wool (padding) · Layer 2: crepe bandage (shape) · Layer 3: light compression (Class 3a) · Layer 4: cohesive elastic (Class 3b). Changed weekly unless heavily exuding.

2-Layer Coban 2 / KTwo

Foam underlayer + cohesive outer. Lighter, easier application, suitable for slender ankles. Equivalent healing rates to 4-layer.

Short Stretch Bandaging (Actico/Comprilan)

High working pressure, low resting pressure — safer for immobile/cardiac patients. Requires more frequent re-application. Preferred in GCC heat (see Tab 6).

Laplace's Law: Sub-bandage pressure ∝ Tension × Number of layers ÷ (Limb circumference × Bandage width). Apply figure-of-8 from toes to knee at 50% overlap.

Compression Hosiery

Maintenance after ulcer healing — primary recurrence prevention

Class I

14–17 mmHg

Mild varicose veins / prevention only — NOT adequate post-VLU

Class II

18–24 mmHg

Post-VLU maintenance — minimum recommended for recurrence prevention

Class III

25–35 mmHg

Severe venous disease / high-recurrence risk — most evidence-based for VLU

Application Aids:

Butler frame · Medi Valet · Juzo Easy-Slide · silk donning gloves. Assess hand strength and dexterity.

Concordance Challenges:

Discomfort in heat · difficulty application · cosmetic concerns · cost · lack of understanding of importance → Educate on recurrence rates without hosiery (70% at 3 years)

Contraindications to Full Compression

✗

ABPI < 0.8

Significant peripheral arterial disease — arterial compromise

✗

Acute / Unresolved DVT

Without anticoagulation and specialist guidance

✗

Congestive Cardiac Failure (CCF)

Risk of acute fluid overload — require cardiology clearance first

Peripheral Neuropathy

ABPI must be confirmed before compression — patient cannot report ischaemic pain

Severe rheumatoid / fragile skin

Use light compression with adequate padding; specialist review

Additional Compression Modalities

Intermittent Pneumatic Compression (IPC)

Indicated for immobile patients unable to activate calf muscle pump. Sequential multi-chamber sleeves 40–70 mmHg. Daily use, 1–2 hours. Complements compression bandaging. Reduces oedema and promotes healing in recalcitrant VLU.

Doppler Training for Community Nurses

Nurses performing ABPI require structured training: anatomy · hand-held Doppler technique · waveform interpretation · documentation · competency assessment. Annual revalidation recommended. Quality of signal affected by calcification (diabetes).

Modified Compression (ABPI 0.5–0.79)

Reduced compression 15–25 mmHg. Short stretch preferred. Weekly Doppler monitoring. Multidisciplinary input from vascular team. Written care plan with clear escalation triggers.

TIME Framework — Wound Bed Preparation

Tissue

Remove non-viable tissue. Debride necrosis/slough. Promote granulation.

Infection

Manage bacterial burden. Identify critical colonisation vs clinical infection.

Moisture

Balance moisture — prevent maceration and desiccation. Select appropriate dressing.

Edge

Wound edges not advancing? Consider biopsy, biofilm, inadequate compression.

Debridement Options

Autolytic (passive)

Hydrocolloids / hydrogels — harness body's own enzymes. Safe, painless, slow. For moderate slough.

Mechanical / Sharp

Scalpel / forceps / curette by trained clinician. Fast but requires skill. Pre-medicate with analgesia.

Larval Therapy (biosurgery)

Sterile Lucilia sericata larvae in net bags. Digest slough/necrosis selectively. Effective for recalcitrant sloughy VLU. Change every 3 days.

Enzymatic

Collagenase (e.g. Santyl) — targets specific necrotic tissue. Less common in VLU.

Dressing Under Compression

Primary dressing must be thin, non-bulky, and non-adherent

Wound State	Primary Dressing	Secondary
Low exudate / granulating	Non-adherent / soft silicone (Mepitel)	Thin foam / absorbent pad
Moderate–high exudate	Foam / alginate / hydrofibre	Absorbent secondary + skin barrier
Sloughy	Hydrocolloid / hydrogel	Foam secondary
Fragile periwound	Soft silicone non-adherent (Safetac)	No tape on skin — cohesive bandage only

Infection Management

Critical Colonisation (biofilm)

Stalled healing · increased exudate · friable granulation · no systemic signs

Antimicrobial dressings:

Silver (Aquacel Ag / Mepilex Ag) · Cadexomer iodine (Iodosorb) · Medical-grade honey (Medihoney) · PHMB (Kerracontact)

Clinical Infection (NERDS+STONEES)

Non-healing · exudate ↑ · red granulation · debris · smell + systemic signs

Systemic antibiotics:

Swab for C&S first. Empirical: flucloxacillin 500mg QID (Staph/Strep). Allergy: clarithromycin 500mg BD. Adjust per sensitivities.

Cellulitis (Spreading Infection)

Warmth · erythema · tracking · fever · lymphadenopathy

Management:

Mark margins with pen. Systemic flucloxacillin / IV if severe. Compression should continue unless very painful — wrap loosely. Refer if non-responsive 48h.

Pain Management

EMLA cream (lidocaine/prilocaine) under occlusive dressing 60 min before dressing change. Pre-procedure oral analgesia (paracetamol/ibuprofen). For neuropathic pain: amitriptyline/gabapentin. Distraction and positioning.

Venous Eczema Treatment

Topical steroid (moderate potency e.g. betamethasone valerate 0.1%) short-term 1–2 weeks. Regular emollient (aqueous cream or unperfumed). Avoid preservatives (lanolin, parabens) — high sensitisation risk in VLU. Patch test if uncertain.

Healed VLU — Recurrence Prevention

Recurrence rate: 70% at 3 years without compression hosiery

Lifetime Compression Hosiery (Class II–III)

Most evidence-based intervention. Minimum Class II (18–24 mmHg). Apply each morning before rising. Replace every 3–6 months.

Leg Elevation

Elevate above heart level when sitting/resting. Avoid prolonged dependent position. Use footstool at correct height.

Exercise Programme

Ankle pumps (20 reps hourly) · Calf raises · Walking 30 min/day. Activates calf muscle pump — the heart of the leg.

Skin Care

Daily inspection · moisturise with unperfumed emollient · protect from minor trauma · avoid harsh soaps.

Weight & Lifestyle

Weight management · smoking cessation · avoid prolonged standing/sitting. Occupational advice where relevant.

Vascular Surgery Referral Triggers

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ABPI < 0.8 (any PAD)

Arterial assessment + possible revascularisation

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Failed to heal at 12 weeks

With appropriate compression — investigate for underlying cause

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Suspected malignancy / atypical

Biopsy + specialist review urgently

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Significant lipodermatosclerosis

Superficial venous surgery (EVLA/stripping) reduces recurrence rates

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Recurrent VLU (2+ episodes)

Duplex USS + consideration of superficial venous ablation

Evidence: EVLA/stripping of great saphenous vein incompetence in VLU patients reduces recurrence from 56% → 27% at 3 years (ESCHAR trial).

Patient Self-Management & Community Care Pathway

Patient Self-Management Skills

✓ Daily skin inspection (mirror if needed)

✓ Correct donning/doffing of compression hosiery

✓ Early reporting of skin breakdown, erythema, warmth

✓ Regular physical activity — ankle pumps, walking

✓ Foot/leg elevation technique and timing

✓ Avoiding trauma, heat, tight footwear

Community Nursing Care Pathway

1 Initial assessment: full history + ABPI + wound assessment

2 Commence compression if ABPI ≥ 0.8; dressing under bandage

3 Weekly review: wound measurement + photographic record

4 Reassess ABPI every 3 months or if deterioration

5 Healed: transition to compression hosiery + education

! Not healing at 12 weeks → refer vascular surgery / tissue viability

GCC Clinical Context

Epidemiology

VLU prevalence lower than Western rates historically, but rising with GCC obesity epidemic (35–40% adult obesity rates) and sedentary lifestyles. Post-DVT sequelae in migrant workers increasing.

Occupational Risk Factors

Prolonged standing in domestic workers, retail, construction, hospitality — high-risk population. Heat and humidity (40°C+) worsening oedema and venous hypertension.

Compression in GCC Climate

4-layer bandaging poorly tolerated in extreme heat — sweating, discomfort, malodour. Short stretch bandaging (Actico/Comprilan) or foam-layer systems preferred: lighter, breathable, maintain effectiveness. Hosiery concordance challenging — cultural leg coverage may help or hinder.

Diabetic Co-morbidity

GCC has world's highest T2DM rates (20–25% adults). Mixed aetiology ulcers common — venous + neuropathic + ischaemic. ABPI may be falsely elevated due to calcification. Toe pressure / TBI essential. Multidisciplinary DFU & VLU pathways needed.

Healthcare Infrastructure

DHA community nursing VLU pathway (Dubai) · DOH Abu Dhabi community services · SCFHS-regulated nurses (Saudi Arabia). District nursing equivalent services developing across GCC. Tissue Viability Nurse (TVN) specialist role expanding.

DHA / DOH / SCFHS Exam Prep

CEAP Classification — KEY EXAM POINTS

C4b = lipodermatosclerosis (NOT C4a). C5 = healed ulcer. C6 = active ulcer. Suffix E = aetiology (Ep=primary, Es=secondary post-DVT). CEAP does NOT replace clinical judgement.

ABPI Before Compression — MANDATORY RULE

Never apply compression without ABPI. Normal = 0.8–1.2. ABPI < 0.8 = modified/no compression. >1.3 in diabetes = use toe pressure. This rule appears in almost every wound care exam.

4-Layer Bandage Indications

First-line for VLU with ABPI ≥ 0.8. Target 40 mmHg at ankle. Changed weekly. Each layer has specific function. Contraindicated: ABPI <0.8, acute DVT, CCF, severe ischaemia.

Dressing Selection Principles

Match dressing to wound state (exudate level, tissue type). Under compression: non-bulky primary. Antimicrobial for biofilm/critical colonisation. Systemic antibiotics only for clinical infection with systemic signs.

Quick Reference — High-Yield Exam Facts

70%

VLU recurrence at 3 years without compression hosiery

40 mmHg

Sub-bandage pressure at ankle for high compression

<0.5

ABPI — no compression, urgent vascular referral

12 wks

Non-healing at 12 weeks → refer vascular / biopsy

ESCHAR

Trial: venous surgery 56%→27% recurrence at 3 years

CEAP class for active venous ulcer (C5 = healed)

TIME

Tissue · Infection · Moisture · Edge — wound bed prep

>1.3

ABPI — calcified (diabetic) — use toe-brachial index

Leg Ulcer Assessment & Compression Planner

Interactive clinical decision support — complete the fields below to generate a personalised care recommendation

Ulcer Location

Wound Bed Description

ABPI Value

Pain with Compression

Cardiac Failure (CCF)

DVT History