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Compression stockings
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Exam Tips
- Always quote ABPI thresholds in OSCEs: <0.8 contraindicates compression, 0.8-1.3 usually safe, >1.3 needs specialist vascular review.
- List key contraindications: suspected PAD, arterial bypass graft, significant neuropathy/sensory loss, fragile/damaged skin or recent graft, severe oedema, acute infection, suspected DVT, stocking material allergy, major limb deformity, suspected skin cancer.
- Know class pressures (British Standard): class 1 = 14-17 mmHg, class 2 = 18-24 mmHg, class 3 = 25-35 mmHg.
- Condition-based choice: varicose veins usually class 1-2; venous eczema/lipodermatosclerosis/healed ulcer usually class 2, escalate to class 3 if needed and tolerated.
- If ABPI cannot be obtained because of oedema and no red flags, use temporary low compression up to 20 mmHg and repeat ABPI soon (about 1 week).
- See Figure: ABPI interpretation and compression decision pathway in vascular assessment teaching diagrams.
Definition
Compression stockings are graduated elastic garments used in chronic venous disease to reduce venous hypertension, improve calf-muscle pump efficiency, and support venous return from ankle to thigh. In UK practice they are mainly used for symptomatic varicose veins, venous skin change, and healed venous ulcer care after arterial disease has been excluded with ABPI assessment.
Pathophysiology
Chronic venous insufficiency arises from venous valve incompetence and/or prior deep venous obstruction, causing ambulatory venous hypertension, capillary leak, oedema, inflammation, and skin damage (for example haemosiderin deposition, lipodermatosclerosis, and ulceration). Graduated compression applies highest pressure distally and lower pressure proximally, reducing venous pooling, increasing venous flow velocity, and augmenting calf-pump function. British Standard classes are defined by ankle pressure: class 1 (14-17 mmHg), class 2 (18-24 mmHg), class 3 (25-35 mmHg). See Figure: venous valve incompetence and calf-muscle pump failure diagram in a standard vascular physiology textbook.
Risk Factors
- Previous deep vein thrombosis or post-thrombotic venous damage
- Previous leg surgery, trauma, or infection
- Family history of venous disease
- Prolonged standing occupation and reduced calf-muscle activity
- Obesity and pregnancy (contributors to venous hypertension)
- Increasing age
Clinical Features
Symptoms
- Leg aching or pain worse on standing
- Heaviness or swelling of lower legs
- Itching around venous eczema areas
- Discomfort related to superficial varicosities
- History of recurrent ulceration or delayed wound healing
Signs
- Varicose veins
- Pitting oedema (after excluding non-venous causes)
- Venous dermatitis/eczema
- Haemosiderin staining (brawny discoloration)
- Lipodermatosclerosis
- Atrophie blanche
- Healed or active venous leg ulcer
Investigations
Ankle-brachial pressure index (ABPI) in both legs with Doppler:ABPI 0.8-1.3 supports safe compression use; <0.8 suggests significant arterial insufficiency (avoid compression, urgent vascular assessment); >1.3 suggests calcified incompressible vessels (avoid compression, specialist vascular assessment).
Clinical skin and limb assessment:Confirms venous stigmata, assesses fragile skin, deformity, oedema severity, and suitability for fitting/adherence.
Duplex ultrasound (vascular service):Defines superficial/deep venous reflux and anatomy; used when symptomatic/complicated varicose veins are referred for intervention.
Management
Lifestyle Modifications
- Measure and fit correctly (below-knee or thigh length) and use the highest tolerated class for the indication.
- Educate on daily wear, skin moisturising, and replacing hosiery at recommended intervals.
- Encourage walking/calf exercises and leg elevation when resting to reduce venous pressure.
- Use donning aids or community nursing support if reduced dexterity/mobility.
- Reassess at follow-up for symptom response, skin integrity, and tolerance.
Pharmacological Treatment
Analgesia (adjunct for painful superficial venous inflammation)
- Ibuprofen 400 mg orally three times daily with food (max 2.4 g/day prescribed)
- Paracetamol 1 g orally every 4-6 hours as needed (max 4 g/day)
Not a substitute for compression assessment. Avoid or use caution with NSAIDs in CKD, peptic ulcer disease, heart failure, anticoagulation, or high GI risk.
Topical therapy for associated venous eczema
- Hydrocortisone 1% cream/ointment applied once or twice daily for mild flares
- Emollient (for example 50:50 white soft paraffin/liquid paraffin) applied liberally several times daily
Use shortest effective steroid course; monitor for skin atrophy with prolonged steroid use.
Surgical / Interventional
- Refer symptomatic or complicated varicose veins to vascular service.
- For confirmed truncal reflux, treatment sequence is typically endothermal ablation, then ultrasound-guided foam sclerotherapy, then surgery; compression hosiery is used when intervention is unsuitable or as adjunct care.
- Do not offer elastic graduated compression stockings solely to prevent post-thrombotic syndrome or recurrent VTE after proximal DVT.
Complications
- Progressive skin damage (eczema, lipodermatosclerosis, atrophie blanche)
- Venous leg ulceration or recurrence
- Bleeding from superficial varicosities
- Recurrent cellulitis in chronically oedematous legs
- Compression-related pressure injury or ischaemia if used despite contraindications
Prognosis
With correct assessment (especially ABPI), proper fitting, and good adherence, compression improves symptoms and reduces oedema and venous skin deterioration; recurrence is common if treatment is inconsistent. Prognosis is poorer with severe reflux, mixed arterial-venous disease, immobility, or intolerance/non-adherence to hosiery.
Sources & References
✅NICE Guidelines(1)
- Compression stockings[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1414)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1666, 1667)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1769)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 332, 333)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 455)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 288)[context]
- Emergencies in - Obstetrics and Gynaecology, Second Edition (Stergios K. Doumouchtsis, S. Arulkumaran) (Z-Library).pdf(pp. 95, 96)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 194, 195)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 194)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 237, 238)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 238, 239)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 236)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 237, 238)[context]
- Oxford Handbook of Clinical Diagnosis (Huw Llewelyn, Hock Aun Ang, Keir Lewis etc.) (Z-Library).pdf(pp. 209)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 581)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 581, 582)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 109)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 833)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1080, 1081)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 108, 109)[context]