Compression therapy for non‐venous leg ulcers: Current viewpoint

Compression therapy is utilised to enhance venous return and reduce lower extremity edema to promote wound healing.1 Following Laplace's law, the resulting sub-bandage pressure is directly proportional to the tension of the applied fabric and indirectly proportional to the radius of the limb. This principle is the basis for the application of compression therapy to improve calf muscle function, restore valve competence, and reduce venous reflux. The compression therapy is the evidence-based standard care for management of venous leg ulcers.1 However, the compression therapy is only rarely used in leg ulcers of non-venous aetiology. Although 75% of chronic leg ulcers are purely venous or mixed arteriovenous, acute wounds of the legs and atypical leg ulcers are an important group of ulcers for the clinicians. Most of these ulcers are painful and significantly affect patients' daily activities. Treating the cause is the mainstay of the treatment, but proper wound care is critical to shorten the time to healing. Majority of these ulcers have a secondary venous insufficiency and limitation in calf muscle function. Integrating the compression therapy in non-venous ulcers is lacking the evidence. What is the role of compression therapy for leg ulcers due to non-venous aetiologies? The truth is that we cannot answer this simple question in certain. We have conducted a literature review to assess this issue. A PubMed search included articles in the English language, published between 2000 and 2018, with keywords "compression therapy of lower limbs/extremities." Our search was using keywords plus compression therapy: "chronic leg ulcers" and compression therapy, "pyoderma gangrenosum" and compression therapy, "cutaneous leukocytoclastic vasculitis," or "vasculitis" and compression therapy, "sickle cell anemia" and compression therapy, and "necrobiosis lipoidica" and compression therapy. A total of 1926 publications have been found out of which 304 were review articles, but most of them are related to neurological compression injuries. After limiting the search only to publications that include compression, therapy, and/or lower limbs/extremities, the list was narrowed to 69 articles that dealt with lower limb management and finalised to 33 after further appraisal of their content, as strictly pertaining to our subject of interest and contained only the keywords within the title of the publication and discussed clinical aspects of the subjects. The results indicate that 76% (25/33), 21% (7/33 combined with venous), 21% (7/33), and 12% (4/33) of these reports address the application of compression therapy for venous disease, lymphedema, deep venous thrombosis prophylaxis, and other causes, respectively. For which, not surprisingly, sufficient data exist to support their well-accepted and established consensus on the compression treatment (Table 1). CVI VLU CVI Lymphedema Lipedema CVI Lymphedema Lower extremity lymphedema CVI Trauma induced edema CVI DFU CVI Lymphedema Leg ulcers CR Compression Rx is cost effective DVT prophylaxis Thigh-length stockings vs below knee stockings for DVT prophylaxis 10 articles selected 4 RCT's As provided in Table 1, only limited evidence supports the use of compression for non-venous ulcers; however, experimental data suggest a potential benefit for patients with well vascularized leg ulcers of non-venous aetiology. For atypical wounds such as traumatic ulcers, wounds due to pyoderma gangrenosum (PG), necrobiosis lipoidica (NL), vasculitis, and any other chronic wounds, they may potentially present to wound healing clinics. However, this was not the real subject of our interest; we wanted to inquire how about applying this therapy for non-venous or related diseases. We have become attended to this issue, since, based on our clinical experience, applying compression is apparently obvious to be provided for any given lower extremities' wounds, but is that really? Compression stockings were recommended in the literature for the management of non-venous leg ulcers including cutaneous vasculitis in lower extremities to reduce purpura. The authors of this article have argued that although no studies exist to support their statement, it is pathophysiologically appropriate and not with major adverse effects.2 Compression therapy has a crucial role on wound healing particularly when edema is present regardless of aetiology. A case series of three reported patients with chronic leg ulcers and anaemia have failed to respond to the haematological therapy but healed with an appropriate compression therapy.39 PG is a chronic painful inflammatory ulcer that commonly involves lower extremities. One report signifies the importance of combined multimodal therapy, including immunosuppressive, wound care that includes compression therapy, the latter as negligible. While another report indicates complete healing of PG, only with conservative therapy of wound healing including compression therapy, although this raises some questions regarding the stability of such long-term regimen in an inflammatory disorder such as PG, it emphasises the importance of utilising compression to such wounds.3 Nevertheless, in another study investigating chronic leg ulcers in patients, more than 100 adult patients with rheumatological diseases, of whom 17 have suffered from PG, were treated with the compression therapy alone and exhibited successful results.4 In contrast to this, another study of 103 PG patients treated with multiple treatment modalities include tissue debridement but did not include any compression therapy.40 NL is another chronic granulomatous cutaneous disorder that mostly present in the lower shins is commonly associated, but not restricted to diabetic patients. The compression therapy is part of management plan for all NLs located on lower extremities. We have found only one report that combined compression therapy to the regimen; although it was a successful therapy with almost complete healing, success was not attributed to the compression at all.5 It is essential to remember that compression therapy should be managed with caution in cases of significant arterial disease or symptomatic congestive heart failure. Adherence to treatment is another challenge for the application of compression therapy to extremely painful ulcers such as PG that can be addressed with proper counselling. Compression therapy is mostly known to be used for chronic venous ulcers and lymphedema, with obvious rationale and with robust evidence-based data. Compression therapy is the evidence-based standard care for management of venous leg ulcers. However, compression therapy is only rarely used in leg ulcers of non-venous aetiology. *****************How about application of compression therapy for other indications? Even though the evidence is limited, most experts are applying compression therapy to lower extremity ulcers to improve the healing. It is possible that many patients with lower extremity ulcers have a functional venous insufficiency. Application of compression therapy improves the calf muscle function and reduce the edema. We have experienced good results in our practice. We assume that unless contraindicated to do so, compression therapy may be beneficial for almost any given lower leg ulcer. Therefore, based on our experience, and much less due to the lack of robust evidence, at this point, we conclude to the question whether to use compression or not to use compression? we choose to use compression, well, at least until proven otherwise. We strongly recommend that further future studies will address this issue to make our assumption more solid. A.A. has consulted for AbbVie, Janssen, LEO, Galderma, Novartis, and Valeant, and is also an investigator for AbbVie, Novartis, Regeneron, Pfizer, Boehringer-Ingelheim, Glenmark, Merck Serono, Roche, Xoma, and Xenon. A.A. received an unrestricted educational grant from AbbVie. E.S. has no conflicts of interest.

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