Key messages
• A high level of compression may be more effective for preventing ulcers returning than a lower level of compression or no compression.
• In the long term, people may be more likely to continue using stockings with lower compression.
What are venous leg ulcers?
Venous leg ulcers are long-lasting sores that occur in the legs of people with venous disease. They can be caused by a blockage or sluggish blood flow in the vessels that carry blood back up the legs to the heart.
How are venous ulcers treated?
Compression with bandages or hosiery (stockings, socks, tights) can help heal most venous ulcers. However, venous leg ulcers can come back (recur) after they have healed, or new ulcers can develop in a different location. Continued use of compression therapy after healing may reduce the chance of ulcers recurring.
What did we want to find out?
We wanted to know:
• whether compression prevents the recurrence of venous ulcers anywhere on the treated leg;
• which are the best levels, types, or brands of compression for preventing ulcer recurrence;
• whether people really adapt to the use of compression over the long term; and
• if compression therapy has unwanted effects.
What did we do?
We searched for studies that assessed compression for preventing recurrence of venous ulcers. We compared and summarised their results, and we rated our confidence in the evidence based on factors such as study methods and sizes.
What did we find?
We found eight eligible studies, which included 1995 people with healed venous ulcers. Most participants were women, and the average age ranged from 58 years to 78 years. The shortest study lasted six months, and the longest study evaluated the effects of compression over 10 years. The studies used different levels of compression (UK class 2, UK class 3, European class 1, European class 2, European class 3) and no compression. No studies compared different lengths of compression (e.g. below-knee compared with above-knee).
Main results
European class 3 compression stockings may reduce the likelihood of ulcer recurrence compared with no compression. For every 1000 people using European class 3 compression stockings, 210 may have ulcer recurrence, compared with 457 of every 1000 people who use no compression.
There may be little or no difference in the risk of ulcer recurrence with European class 1 compression stockings compared with European class 2 compression stockings.
UK class 3 compression hosiery may be better than UK class 2 compression hosiery for preventing ulcer recurrence. For every 1000 people using UK class 3 compression hosiery, 342 may have ulcer recurrence, compared with 530 of every 1000 people using UK class 2 compression hosiery. However, people using the class 3 hosiery may be more likely to stop treatment compared with those using the class 2 hosiery (215 per 1000 of those using class 3 hosiery compared with 148 per 1000 of those using class 2 hosiery).
There may be little or no difference between two different brands of UK class 2 compression stockings (Scholl and Medi) in terms of risk of ulcer recurrence and likelihood of people stopping treatment.
We found no information about how long the episodes of recurrence lasted, the risk of ulcers developing in the other leg, the proportion of time during the study that participants had no ulcers, level of comfort, or unwanted effects of compression therapy.
What are the limitations of the evidence?
We have little confidence in the evidence because the participants in most studies knew which treatment they were receiving, because there was considerable variation in the duration of the studies, and because some studies enroled few people.
How up-to-date is this review?
The evidence in this Cochrane review is current to August 2023.
Compression with EU class 3 compression stockings may reduce reulceration compared with no compression over six months. Use of EU class 1 compression stockings compared with EU class 2 compression stockings may result in little or no difference in reulceration and noncompliance over 12 months. UK class 3 compression hosiery may reduce reulceration compared with UK class 2 compression hosiery; however, higher compression may lead to lower compliance. There may be little to no difference between Scholl and Medi UK class 2 compression stockings in terms of reulceration and noncompliance.
There was no information on duration of reulceration episodes, ulceration on the contralateral leg, proportion of follow-up without ulcers, comfort, or adverse effects.
More research is needed to investigate acceptable modes of long-term compression therapy for people at risk of recurrent venous ulceration. Future trials should consider interventions to improve compliance with compression treatment, as higher compression may result in lower rates of reulceration.
Up to 1% of adults will have a leg ulcer at some time. Most leg ulcers are venous in origin and are caused by high pressure in the veins due to blockage or damaged valves.
Venous ulcer prevention and treatment typically involves the application of compression bandages/stockings to improve venous return and thus reduce pressure in the legs. Other treatment options involve removing or repairing veins. Most venous ulcers heal with compression therapy, but ulcer recurrence is common. For this reason, clinical guidelines recommend that people continue with compression treatment after their ulcer has healed.
This is an update of a Cochrane review first published in 2000 and last updated in 2014.
To assess the effects of compression (socks, stockings, tights, bandages) for preventing recurrence of venous leg ulcers.
In August 2023, we searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, three other databases, and two ongoing trials registries. We also scanned the reference lists of included studies and relevant reviews and health technology reports. There were no restrictions on language, date of publication, or study setting.
We included randomised controlled trials (RCTs) that evaluated compression bandages or hosiery for preventing the recurrence of venous ulcers.
At least two review authors independently selected studies, assessed risk of bias, and extracted data. Our primary outcome was reulceration (ulcer recurrence anywhere on the treated leg). Our secondary outcomes included duration of reulceration episodes, proportion of follow-up without ulcers, ulceration on the contralateral leg, noncompliance with compression therapy, comfort, and adverse effects. We assessed the certainty of evidence using GRADE methodology.
We included eight studies (1995 participants), which were published between 1995 and 2019. The median study sample size was 249 participants. The studies evaluated different classes of compression (UK class 2 or 3 and European (EU) class 1, 2, or 3). Duration of follow-up ranged from six months to 10 years. We downgraded the certainty of the evidence for risk of bias (lack of blinding), imprecision, and indirectness.
EU class 3 compression stockings may reduce reulceration compared with no compression over six months (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.27 to 0.76; 1 study, 153 participants; low-certainty evidence).
EU class 1 compression stockings compared with EU class 2 compression stockings may have little or no effect on reulceration over 12 months (RR 1.70, 95% CI 0.67 to 4.32; 1 study, 99 participants; low-certainty evidence). There may be little or no difference in rates of noncompliance over 12 months between people using EU class 1 stockings and people using EU class 2 stockings (RR 1.22, 95% CI 0.40 to 3.75; 1 study, 99 participants; low-certainty evidence).
UK class 2 hosiery compared with UK class 3 hosiery may be associated with a higher risk of reulceration over 18 months to 10 years (RR 1.55, 95% CI 1.26 to 1.91; 5 studies, 1314 participants; low-certainty evidence). People who use UK class 2 hosiery may be more compliant with compression treatment than people who use UK class 3 hosiery over 18 months to 10 years (RR for noncompliance 0.69, 95% CI 0.49 to 0.99; 5 studies, 1372 participants; low-certainty evidence).
There may be little or no difference between Scholl UK class 2 compression stockings and Medi UK class 2 compression stockings in terms of reulceration (RR 0.77, 95% CI 0.47 to 1.28; 1 study, 166 participants; low-certainty evidence) and noncompliance (RR 0.97, 95% CI 0.84.1 to 12; 1 study, 166 participants; low-certainty evidence) over 18 months.
No studies compared different lengths of compression (e.g. below-knee versus above-knee), and no studies measured duration of reulceration episodes, ulceration on the contralateral leg, proportion of follow-up without ulcers, comfort, or adverse effects.