Compression Stockings – NICE / NHS Guide

posted in: Varicose Veins

Compression stockings are useful in treating and guarding against further aggression of chronic venous disorders such as phlebitis, edema, and thrombosis. As is with any other medical procedure, care should be taken from prescription to use of compression stockings.

Compression Stockings Guide by NICE / NHS - Vein Solutions

Assessments that should be carried out before prescription of compression stockings

  • The patient should provide their comprehensive medical and surgical history.
  • Any previous limb infection and/ or trauma
  • Any concurrent illnesses
  • Prior use of medications such as corticosteroids
  • Family history of any genetic venous disease
  • Risk factors for acquiring venous diseases such as deep vein thrombosis, or previous limb surgery

Examine the patient’s legs for the following:

  • Signs of venous conditions such as venous dermatitis, hemosiderin deposition, varicose veins, lipodermatosclerosis, and astrophile Blanche
  • Oedema, exclude any signs of non-venous causes

Exclude arterial deficiencies

Use a Doppler machine to measure the pressure index in the ankle region for both legs. If the pressure index (ABPI) is:

  • Below 0.8 –severe arterial insufficiency is likely, and hence compression stockings are contraindicated. Refer the patient to a specialist for vascular assessment.
  • In the range of 0.8 to 1,3 –it is safe to prescribe compression stockings.
  • Above 1.3 –high ABPI may be as a result of calcified or incompressible arteries. Avoid prescribing compression stockings. Refer the patient to a specialist for vascular assessment.

Examine the patient’s skin condition:

  • If the individual has fragile skin, it might get damaged while pulling the compression stockings on or off.
  • If the individual has not healed from venous ulcers, do not prescribe compression stockings until they recover completely. As with fragile skin, stockings could damage unhealed ulcers.

Analyse the likelihood of the individual managing compression stockings:

Some people might have reduced dexterity and mobility due to age, or infections such as arthritis, making it tedious for the person to pull stockings on or off.

If there is a likelihood that the person will have difficulty, support from the family, or community nursing staff, or an application aid could go a long way in helping the patient.

Basis for Recommendation

The recommendations herein are founded on the Scottish Intercollege Guidelines Network (SIGN) management of severe venous leg ulcers [SIGN,2010], the Compression hosiery [Wounds U.K.,2015], the expert opinion on a consensus document “Simplification of venous leg ulcer management” [Harding, 2015], and “The valuation and merits of made-to-measure hosiery” [JCN, 2015].

How to choose the class of compression stockings

The recommended class of stockings is dependent on the condition being treated. It should, however, be the highest the individual can handle.

  • Varicose veins –class 1 or 2 compression stockings recommended, depending on the levels the patient can tolerate and the severity of the disease.
  • Venous eczema, atrophie blanche, lipodermatosclerosis, and healed venous leg ulcers –class 2 stockings recommended.
  • You could try class 3 stockings if the patient’s reaction to class 2 compression stockings is unsatisfactory.
  • Try class 1 stockings if the patient cannot tolerate class 2 stockings.

Do not prescribe elastic advanced compression stockings to guard against venous thromboembolism recurrence or post-thrombotic syndrome after a proximal deep vein thrombosis (DVT).

  • This recommendation is not inclusive of the use of elastic stockings to manage leg symptoms after DVT.

Superficial thrombophlebitis –class 2 stockings recommended.

  • A majority of patients find class 2 stockings to be too tight, if that is the case, travel socks or class 1 stockings can be useful alternatives

Basis for recommendation

The recommendation that the strongest tolerable compression should be prescribed is based on the SIGN guideline “Management of chronic venous leg ulcers” [SIGN, 2010], and expert opinion on a narrative review “Optimising harmony with compression stockings in the community setting” [Anderson, 2015].

How to choose stocking height

Compression stockings therapy might last a patient’s lifetime. It is, therefore, critical to comply with the patient’s preferences. The final decision on the stocking’s length is primarily belongs to the patient.

Below-knee stockings are mostly recommended:

  • To protect against the recurrence of venous leg ulcers in persons who have healed from leg ulcers.
  • When the inflammation is only on the lower leg, and it is not possible or reliable to use thigh-length stockings.
  • Thigh-high stockings are recommended for people suffering from severe varicose veins or swelling extending to the thigh region.

Basis for recommendation

The above recommendations are founded on the British Medical Journal (BMJ) best practices guide Chronic venous deficiency [BMJ, 2017], the Scottish Intercollege Guideline Network (SIGN) guideline managing severe venous ulcers [SIGN, 2010]. A U.S. guideline on Management of leg ulcers: Clinical practice guidelines of the Vascular Surgery Society and American Venous Forum [O’Deonell, 2014], and expert opinion on a narrative review: Prescribing compression stockings [Todd, 2015].

There is no proof to suggest that one compression type, duration or the preferred stocking length is more or less efficient than another in preventing occurrence or recurrence of venous disease [O’Donell, 2014]

According to a randomised controlled trial that compared compression stocking lengths, thigh-length stockings do not provide better protection against thrombotic syndrome as compared to below-knee compression stockings. They are also less tolerated by patients.

Approximately 30-65% of patients are not compliant with compression therapy [BMJ, 2017].

In order to aid compliance, the CKS recommends that the choice of stocking be left to the patient’s preferences.

The best option between open and closed-toe compression stockings

The final decision between open and closed-toe compression stockings is mainly vested on the patient’s preference.

Open toe compression stockings may be preferable for people who:

  • Have a clawed or arthritic toe, or fungal infection.
  • Prefer to wear pull on a regular sock over the stocking.
  • Have a more extended foot size as compared to their calf size.

The merits of open-toe compression stockings include:

  • Slightly more comfortable to put on
  • May be preferable in hot weather

The demerits of open-toe compression stockings include:

  • They can make painful foot joints more intensified, making it intolerable for the patient.
  • Unlike closed-toe compression stockings, they could slide up the foot, causing the toes to swell.

Basis for recommendation

The basis for these guidelines was the Royal College of Nursing (RCN) guideline “the nursing management of patients with venous leg ulcers [RCN, 2006], the Wounds U.K. Best practice statement: “Compression hosiery” [Wounds U.K., 2015], expert opinion on a narrative review on how to select the best compression stockings for your patient [JCN, 2014], and practices that the CKS considers appropriate.

  • Patients with venous disease may develop the arterial disease, and they may experience significant reductions in the pressure in the ankle-brachial area in a considerably short period of 3-12 months [RCN, 2006]

The frequency of the Doppler assessments will, in practice, be steered by local convenience and resources.

How to ensure the stocking is the right fit for the patient.

Compression stockings come in several sizes. You can determine the right size for your patients by measuring their legs.

  • Measurements can be taken at the pharmacy, and subsequent charges can be claimed for measurement during a compression stockings prescription.
  • If it is not possible to take the measurements at the pharmacy, the patient’s carer may take the measurements. You could also refer the patient back to the compression stockings prescriber to make alternative arrangements.

If the patient is to wear compression stockings on both legs, take measurements for both legs to exclude any substantial inconsistency in size. In the case that there is any considerable size difference, two differently sized compression stockings will have to be ordered.

Units of measurement differ across brands, but in general, you will need the following for below-knee stockings (The measurements should be taken while the person is seated on a chair with their feet sitting flat on the floor surface):

  • The circumference of the narrowest point above the malleoli (ankle bone)
  • Circumference of the mid-calf area (where the calf is widest)
  • The length of both feet, (if the stocking is needed for both legs) from the arch on the heel to the tip of the tallest toe if the closed-toe stocking is preferred

If a thigh-length compression stocking is prescribed, include measurements of the broadest part of the patient’s thigh.

If a patient’s leg is swollen, the measurements should be taken early in the morning. Taking the measurements may require the services of a community nurse.

If a patient’s leg is severely swollen, it may need compression bandaging for some time.

If a patient has a deformity affecting their legs or their legs have no stockings that meet the size requirements, made-to-measure stockings may be needed.

Should patients remove stockings at bedtime?

Generally, compression stockings should be taken off before going to bed and put on early in the morning (to prevent leg swellings from developing or worsening).

If it is not possible to take off the stockings continuously, they cannot be worn for more than seven consecutive days.

How often should the patient replace compression stockings?

Compression stockings should be used for 3-6 months and then replaced

The patient should be provided with at least two compression stockings so that one stocking can be clean while the other is worn.

Ideally, measurements should be taken every time stocking replacement is made.

Correct washing can prolong the life of compression stockings. Hand washing the stockings at a comfortable hand temperature (about 40°C) and then dried off in direct sunlight is recommended.

How often can a patient be reviewed?

Review patients after every 3-6 months to:

  • Reassess the patient’s condition to determine if the stocking class should be changed.
  • Ensure that the patient is wearing the stocking as required and is replacing them in time.
  • Take the leg measurements again to ensure the compression stockings are the correct size.

Doppler studies should ideally be repeated after every 6-12 months or any earlier date that is clinically indicated. If any is available, local policies should be adhered to.

Basis for recommendation

The guidelines above are based on the recommendations of the Royal College of Nursing (RCN): The nursing managing patients with severe venous leg ulcers [RCN, 2006],

How to encourage patient compliance with wearing stockings

Make the patient understand the benefits of wearing and reasons for wearing compression stockings.

Ensure that the patient has been taught how to take off or put on the stocking easily and also that they have been able to do so on their own.

  • If the patient is having difficulty while wearing the stocking, an application aid, such as ActiGlide, may be prescribed.
  • Make the patient understand that the most appropriate time to put on the stocking in early in the morning to prevent any swelling from developing.

Make sure the patient is content with the colour of the compression stocking.

  • Men prefer black, grey, blue, or other colours that are not fleshy.

Make sure that the stockings are the correct size for the patient. A made-to-measure compression stocking could be required if the available sizes do not fit.

If the level of compression is higher than the person can tolerate, try on a looser compression stocking.

If the patient cannot tolerate wearing a thigh-high stocking, try switching to a knee-high stocking. It is usually not a must to prescribe thigh-length stocking.

Make sure the patient understands that the stockings should be removed just before going to bed.

  • Application of an ointment when the stocking is taken off should be recommended to minimise dryness and irritation of the skin under the stockings.

Make sure the patient understands the importance of regular reviews and stocking replacement to ensure they continue to provide the required level of compression and fit correctly.

Basis for recommendation

The above recommendations are founded on the Wounds U.K. good practice statement: “Compression hosiery” [Wounds U.K., 2015], and the practices considered correct by the CKS.


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