Compression therapy for non‐venous leg ulcers: Current viewpoint

Abstract

Dear Editors, Compression therapy is utilised to enhance venous return and reduce lower extremity edema to promote wound healing. 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. 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 wellaccepted and established consensus on the compression treatment (Table 1). 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. 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. 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 Received: 1 September 2019 Accepted: 18 September 2019