Clinical question
Do compression stockings help patients with chronic lower limb edema decrease cellulitis recurrence?
Bottom line
In patients with chronic leg edema, compression therapy reduced cellulitis recurrence to 15% versus 40% with education alone at 6 months. Compression stockings are a good option for patients without contraindications, although real-world uptake may be limited.
Evidence
- In an RCT of 84 patients with edema lasting at least 3 months and a history of cellulitis (2 or more episodes in the same leg over the past 2 years),1 compression was individualized (primarily knee-high, 23 to 32 mm Hg; personal communication with E. Webb, a physiotherapist at Calvary Public Hospital Bruce, in Bruce, Australia; July 21, 2021). Results were statistically significant unless noted.
-
-Comparing compression plus education versus education alone, at 6 months:
-
—Recurrence was 15% with compression versus 40% with education (number needed to treat=4).
-
—Quality-of-life scores improved by 8 points (scale 0 to 100), but this was not statistically significant.
-
—In the compression group, 88% reported wearing these garments 4 or more days per week.
-
—No adverse events were reported.
-
—
-
-Limitations: Not blinded; support provided by lymphedema physiotherapists, which may limit general applicability; trial stopped early based on benefits.
-
-
In a prospective cohort study of 107 patients with chronic edema, edema care (with daily compression, exercise, and skin care) provided in a community services model reduced the incidence of cellulitis from 41.5 per 100 patient-years at baseline to 0 at 6 to 12 months.2
Context
Factors that increase the risk of cellulitis in chronic edema include wounds, male sex, diabetes, and obesity.6
Compression stockings have been shown to increase the complete healing of venous ulcers compared with no compression within 12 months (70% vs 40%).7
Stocking price and cost coverage vary considerably.
Contraindications include severe heart failure (risk of fluid overload) and critical limb ischemia.3
Implementation
Despite limited evidence regarding outcomes,8 the measurement of ankle-brachial index (ABI) is generally recommended before initiating compression. Guidelines for the management of venous insufficiency suggest caution or close monitoring for patients with ABI 0.50 to 0.89 and avoidance of compression with ABI less than 0.50.9 Guidelines for venous ulcer management follow similar recommendations for ABI values less than 0.50 and 0.50 to 0.89.10 Compliance can be increased by including compression stocking–donning assistance in home care orders and considering lower compression levels when edema reduction can still be achieved reasonably.3,4 Some patients may qualify for stocking subsidies through provincial programs.
Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice@cfpc.ca.
Footnotes
Competing interests
None declared
The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the College of Family Physicians of Canada.
References
- 1.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;383(7):630-9. [DOI] [PubMed] [Google Scholar]
- 2.Moffatt CJ, Doherty DC, Franks PJ, Mortimer PS. Community-based treatment for chronic edema: an effective service model. Lymphat Res Biol 2018;16(1):92-9. [DOI] [PubMed] [Google Scholar]
- 3.Rabe E, Partsch H, Hafner J, Lattimer C, Mosti G, Neumann M, et al. Indications for medical compression stockings in venous and lymphatic disorders: an evidence-based consensus statement. Phlebology 2018;33(3):163-84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Kapp S, Miller C, Donohue L. The clinical effectiveness of two compression stocking treatments on venous leg ulcer recurrence: a randomized controlled trial. Int J Low Extrem Wounds 2013;12(3):189-98. [DOI] [PubMed] [Google Scholar]
- 5.Teasdale EJ, Lalonde A, Muller I, Chalmers J, Smart P, Hooper J, et al. Patients’ understanding of cellulitis and views about how best to prevent recurrent episodes: mixed-methods study in primary and secondary care. Br J Dermatol 2019;180(4):810-20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Burian EA, Karlsmark T, Franks PJ, Keeley V, Quéré I, Moffatt CJ. Cellulitis in chronic oedema of the lower leg: an international cross-sectional study. Br J Dermatol 2021;185(1):110-8. [DOI] [PubMed] [Google Scholar]
- 7.Shi C, Dumville JC, Cullum N, Connaughton E, Norman G. Compression bandages or stockings versus no compression for treating venous leg ulcers. Cochrane Database Syst Rev 2021;(7):CD013397. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Wells C, Spry C. Ankle brachial pressure index assessment prior to compression treatment: clinical evidence and guidelines. Ottawa, ON: CADTH; 2017. Available from: https://www.cadth.ca/sites/default/files/pdf/htis/2017/RB1147%20ABPI%20for%20Compression%20Final.pdf. Accessed 2021 Nov 30. [Google Scholar]
- 9.British Columbia Provincial Nursing Skin and Wound Committee . Guideline: application of compression therapy to manage venous insufficiency & mixed venous/arterial insufficiency. Vancouver, BC: BC Patient Safety & Quality Council; 2016. Available from: https://www.clwk.ca/buddydrive/file/guideline-compression-therapy-final-2016-may/. Accessed 2022 Jan 4. [Google Scholar]
- 10.Weller CD, Team V, Ivory JD, Crawford K, Gethin G. ABPI reporting and compression recommendations in global clinical practice guidelines on venous leg ulcer management: a scoping review. Int Wound J 2019;16(2):406-19. [DOI] [PMC free article] [PubMed] [Google Scholar]