17.20 Compression hosiery and garments

Compression garments, hosiery or wraps, are used in the long term management of chronic oedema (usually following compression bandaging), prophylaxis and treatment of venous leg ulceration, and post DVT to prevent post thrombotic syndrome. They may be used with caution for diabetic foot ulceration with oedema, or cardiac oedema, under the direction of a competent practitioner. Please see for additional guidance: NICE CKS Venous Leg Ulcer (February 2016).

Damage to the limb can occur if bandages are applied inappropriately and have led to major amputation. They should not be used for a patient that is in the acute phase following a stroke.

Leg ulceration

The use of graduated compression bandaging, hosiery or wraps, correctly applied, and combined with exercise, is the treatment of choice in venous ulceration. Compression bandaging, hosiery or wraps, may be used in the treatment of mixed aetiology ulcers or where there is suspected arterial incompetency.

If an Ankle Brachial Pressure Index (ABPI) is between 0.5 and 0.8, or above 1.4, consult a vascular surgeon, tissue viability nurse, or lymphoedema specialist before considering compression treatment.

Leg ulcers should be reviewed and reassessed at least every four weeks, the patient should be monitored at each dressing change and the treatment, including any compression therapy reviewed.

Chronic oedema

Chronic oedema is a term used for all forms of oedema that persist for 3 months, irrespective of aetiology. It can be mild to severe; simple or complicated; and with or without wounds.

Investigations should be done to determine the cause and treatment instigated for acute oedema, to reduce and stabilise before addressing and implementing compression therapy. Additional advice is available from the specialist teams listed below.

Guidelines to obtain maximum clinical function and cost effectiveness:

Compression measuring and therapy should only be undertaken by practitioners that have received training and are deemed competent and confident.

A holistic and arterial assessment, Doppler or if not possible clinical signs, should be carried out prior to compression use. Consider co-morbidities, understanding, dexterity, skin fragility, concordance, tolerance, and safety. Those with an Ankle Brachial Pressure Index between 0.5-0.8 and with no other arterial signs may still be considered for compression.

Patients may require compression bandaging to reduce the oedema, heal wounds, stop lymphorrhoea leakage, and reshape limbs prior to compression hosiery or device use. Below knee compression will be the preference for most patients; however if the disease extends above the knee, thigh high should be considered.

Patients with compression treatments should be monitored, and adjustments made to the compression, e.g. size, type, class, correct positioning according to individual needs. This can be completed via a visit, an appointment or over the telephone, but face-to-face contact is recommended at a minimum of every 6 months, and should include a circulatory check. It is advised that compression hosiery be prescribed in 2 pairs every 6 to 12 months; one to wear, one to wash, as appropriate for type, frequency of change, and wear conditions.

Some patients may benefit from wearing a form of compression only during waking hours, and others for 24 hours a day.

Advice can be sought from:

North Devon Lymphoedema Service Contact Details:

Northern Devon Healthcare NHS Trust

  • Northern Devon Lymphoedema Service
    • Telephone: 01271 341551

Tissue Viability Team Contact Details:

Northern Devon Healthcare NHS Trust

Royal Devon and Exeter NHS Foundation Trust

Classification of compression

Compression hosiery comes in a multitude of shapes, sizes and classification testing standards, such as BS (British Standard), RAL (German Institute for Quality Assurance and Certification), and AFNOR (French national standard organisation).

Please ensure that when prescribing Compression Hosiery that consideration is given to the amount of compression you wish to achieve for your patient, regardless of classification. The below tables will act as a guide to support the right choice for the patient, and reduce potential prescribing errors.

BS Pressure Applied Recommended Use
Class I 14 - 17 mmHg Mild
Class II 18 - 24 mmHg Moderate - Severe
RAL Pressure Applied Recommended Use
Class I 18 - 21 mmHg Mild
Class II 23 - 32 mmHg Moderate
Class III 34 - 46 mmHg Moderate - Severe
Class IV >49 mmHg Severe

In the RAL classification some companies may have an F or an S after the compression class e.g. Class 3F, this indicates a stiffer fabric.

Types of compression stockings

CIRCULAR (ROUND) KNIT: the material is continuously knitted on a cylinder, has no seam, and is used mainly to make ready to wear garments. These garments may be thinner and more cosmetically acceptable than flat knit garments.

FLAT KNIT: these are knitted flat and joined by a seam. The material is firmer and thicker than circular knit; with most custom garments made this way. These are a good choice for shape distortion and skin crease to prevent cutting and causing skin trauma.

  • Compression hosiery can be slept in if preferred, up to a maximum of 7 days (NICE CKS Compression stockings (September 2012)). This may be particularly beneficial for patients with impaired dexterity
  • Patients should be shown how to apply compression hosiery and garments, and offered hosiery applicators to aid application and reduce risk of trauma when applying (see hosiery applicators below)
  • It should be noted that while compression hosiery is extremely effective when being worn it does not repair damaged valves or vein walls. Consider vascular referral for eligibility for corrective surgery/sclerotherapy.

Compression hosiery (standard)

The ready to wear devices are as stated below but there are custom products available for those with measurements outside of the range. Consider the wide variety of sizes available in the formulary prior to prescribing made-to-measure.

JOBST® Opaque
  • Compression hosiery ready to wear (from £26.92) (one pair)
  • RAL Class I (18-21 mmHg), Class II (23-32 mmHg)
  • Circular knit
  • Below knee or Thigh length, Black, Navy or Sand, Closed or Open toe
  • Six ready-to-wear sizes

Notes

  1. Light to medium compression
  2. Extra wide variants and silicone top bands available
  3. Clinical effectiveness of 6 months daily use
Haddenham® Veni
  • Compression hosiery ready to wear (from £27.50) (one pair)
  • RAL Class I (18-21 mmHg), Class II (23-32 mmHg), Class III (34-46 mmHg)
  • Circular knit
  • Below knee or Thigh length, Beige or Black, Closed or Open toe
  • Sizes I, II, III, IV, V, VI, VII, VIII
  • Short, Regular, and Long length

Notes

  1. Soft and comfortable for mild to more stubborn oedema
  2. Extra wide variants, waist attachments, and silicone top bands available
  3. Clinical effectiveness of 6 months daily use
Mediven® for Men
  • Compression socks (from £28.37) (one pair)
  • RAL Class I (18-21 mmHg), Class II (23-32 mmHg)
  • Circular knit
  • Below knee, Grey, Navy, Black, Closed toe
  • Sizes I, II, III, IV, V, VI, VII
  • Regular or Petite leg length

Notes

  1. Ultra-modern ribbed office sock
  2. Fits UK shoe sizes 3 to 11
  3. Clinical effectiveness of 6 months daily use
JOBST® for Men Explore
  • Compression socks (from £28.28) (one pair)
  • RAL Class I (18-21 mmHg), Class II (23-32 mmHg)
  • Circular knit
  • Below knee, Black, Dark Grey, Navy, or Khaki, Closed toe
  • Sizes 1, 2, 3, 4, 5, 6
  • Regular or Long length

Notes

  1. Work and leisure style sock
  2. Clinical effectiveness of 6 months daily use
Sigvaris Cotton®
  • Compression hosiery ready to wear (from £27.25) (one pair)
  • RAL Class I (18-21 mmHg), Class II (23-32 mmHg), Class III (34-46 mmHg)
  • Circular knit
  • Below knee, Thigh length or Tights, Nature or Black, Closed or Open toe
  • Sizes XXSmall to XLarge Plus
  • Short, Normal or Long leg length

Notes

  1. For use in patients with skin sensitivities
  2. Waist attachments and grip tops available
  3. Clinical effectiveness of 6 months daily use
Activa® British Standard
  • Compression hosiery ready to wear (from £8.30) (one pair)
  • BS Class I (14-17 mmHg), Class II (18-24 mmHg)
  • Circular knit
  • Below knee or Thigh length, Black, Honey or Sand, Closed or Open toe
  • Small to XLarge

Notes

  1. Clinical effectiveness of 3 months daily use
  2. Not to be used if any oedema present

Compression hosiery (patient specific made-to-measure)

JOBST® Elvarex®
  • Compression hosiery Made-to-measure (from £39.73) (one pair)
  • RAL Class I, Class II, Class III, Class IIIF, Class IV, Class IVS
  • Flat knit
  • Below knee, Thigh length, or Tights, Dark Blue, Dark Brown, Beige, Black, Grey, Closed or Open toe

Notes

  1. Flat lying accommodating limb distortion, reducing risk of trauma and skin damage
  2. Effective mobilisation of oedema
  3. Waist attachments, silicone bands, and toe caps available
  4. Clinical effectiveness of 6 months daily use

Compression hosiery kits

Compression hosiery kits can be used for the treatment of venous and mixed aetiology leg ulcers. Hosiery kits are used for patients with ABPI above 0.8, unless under the guidance of a specialist.

Suitable for patients that have a degree of dexterity and can use an application device, or who have family who can help apply the hosiery on at least a twice-weekly basis.

No form of compression should be used without a full leg ulcer assessment, with Doppler, being undertaken.

Ensure that patients/carers understand the need for appropriate care of hosiery; for example different products may have different washing instructions.

Altipress® 40 ulcer kit
  • Medical Stocking and Compression Liner (pack contains 1 stocking and 2 liners) (£14.50)
Activa® Leg Ulcer Hosiery kit 40mmHg
  • Medical Stocking & Compression Liner (pack contains 1 stocking and 2 liners - 40mmHg) (£22.66)

Compression wraps

These can reduce foot, lower leg, knee, or thigh oedema; and be used in the treatment of leg ulcers. They are an option if hosiery is not tolerated, dexterity and mobility are limited, there are donning and doffing hosiery problems, or thigh compression is required.

They may be cost-efficient in that wraps can reduce qualified input (time saving) and other resource costs (being machine washable and reusable). They may encourage independence and self-management and can be worn over compression hosiery to deliver additional compression. They provide low resting and high working pressures and can be worn day and night.

Juzo® ACS light
  • Lower extremity adjustable compression system (from £35.44)
  • Compression levels up to 40 mmHg
  • Black
  • Sizes 1, 2, 3, 4, 5 (XSmall to XLarge)

Notes

  1. Adaptable whilst wearing for optimal compression
  2. Self-managing with built-in liner aid
JOBST® FarrowWrap®
  • Lower extremity wrap compression system (from £36.39)
  • Lite (20-30 mmHg), Classic (30-40 mmHg), Strong (30-40 mmHg)
  • Foot-piece, Leg-piece, Thigh-piece
  • XSmall to XLarge
  • Liners (see below)

Notes

  1. Lite – A double laminated fabric suitable for mild to moderate oedema
  2. Classic – Rigid fabric with a comfortable feel suitable for moderate to severe oedema with an irregular limb shape
  3. Strong – Soft inner layer which is less rigid than Classic suitable for moderate to severe oedema
  4. Liners are included with the JOBST FarrowWrap, with Silver sent as standard, FarrowHybrid and TG Soft need to be requested on the prescription
JOBST® FarrowWrap® (Liners)
  • Silver liners
    • Antimicrobial silver
    • Beige
    • Knee high only
  • TG® Soft liners
    • Terry cloth
    • Thick, soft and stretchy
    • Knee high and Thigh high
  • JOBST® FarrowHybrid® liners
    • 20-30 mmHg for mild to moderate oedema
    • 30-40 mmHg for moderate to severe oedema
    • Provides compression in the foot and ankle only
    • Knee high only

Toe compression caps

Toe caps provide compression for the prevention and reduction of toe swelling. They are ultra-thin and can be used under other bandage products.

Haddenham Microfine® Toe Cap
  • Compression garment (£26.92) (one)
  • 20-36mmHg
  • Sizes XSmall to XLarge
  • Sand or Black

Hosiery applicators

To work effectively, compression hosiery (below knee, thigh high, and tights) must apply the right amount of pressure to the leg. This often means that the garments can be difficult to put on and take off. Donning and doffing aids reduce the amount of physical effort involved, which may increase compression use compliance and aid independence.

Household rubber gloves can be a cost efficient and simple aid for the application of compression hosiery. All the following products are available to be prescribed on FP10.

Arion Easy-Slide®
  • Applicator (£12.46)
  • Washable material
  • For Open toe
Arion Magnide®
  • Applicator (£14.32)
  • Minimises physical strain
  • Open and Closed toe
Juzo® Easy Fit
  • Applicator and removal device (£34.27)
  • Size L, <26cm ankle circumference
  • Size XL, >26cm ankle circumference
  • Open and Closed toe

 

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