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Compression stockings - Management
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What assessment should I carry out before prescribing compression stockings?

  • Exclude arterial insufficiency:
    • Measure the ankle-brachial pressure index (ABPI) using a Doppler machine (some experts suggest that this is unnecessary if foot pulses are easily palpable, the person has no symptoms of arterial disease, and strong compression is not being applied).
      • ABPI less than 0.5: compression stockings should not be worn, as severe arterial disease is likely.
      • ABPI between 0.5 and 0.8: apply no more than light (class 1) compression, as arterial disease is likely and compression may further compromise arterial blood supply.
      • ABPI greater than 0.8: compression stockings are safe to wear.
      • ABPI greater than 1.3: avoid compression, as high ABPI values may be due to calcified and incompressible arteries. Consider seeking a specialist vascular assessment.
  • Check the condition of the skin:
    • Fragile skin may be damaged while trying to put on or take off compression stockings.
    • Ideally, venous ulcers should be healed before using compression stockings.
  • Consider whether the person is likely to be able to manage compression stockings:
    • Conditions such as arthritis, especially in older people, may make it difficult for the person to put on or take off stockings.
    • If the person is likely to have difficulty, an application aid may be helpful, or support from community nursing staff may be needed.
Basis for recommendation
  • Compression applied to legs with poor arterial circulation can cause limb ischaemia and tissue necrosis. Although easily palpable pulses indicate that the arterial circulation is good, some evidence indicates that relying on palpation of pulses alone may underestimate the prevalence of significant arterial impairment [SIGN, 1998; RCN, 2006].
  • Recommendations regarding ABPI thresholds for use of compression stockings are based on expert opinion [Johnson, 2002; Wounds UK, 2002; RCN, 2006] and information from manufacturers' websites.
  • Graduated multi-layer compression bandaging is the preferred treatment for venous ulcers, as good evidence indicates that this is the most effective treatment (see the CKS topic on Leg ulcer - venous). The main role for compression stockings is to prevent recurrence of venous ulcers. If compression stockings are used in people with venous ulceration, care is needed to avoid traumatizing the ulcer when putting on and taking off the stocking.

How do I decide on the strength of compression?

  • The recommended degree of compression depends on the condition being treated. If the person cannot tolerate the preferred compression for their condition, try the next level down:
    • Varicose veins — class 1 or 2 stockings, depending on the severity of the varicose veins (see the CKS topic on Varicose veins).
    • Venous eczema — class 1 or 2 stockings.
    • Lipodermatosclerosis, atrophie blanche, healed venous leg ulcers — class 2 stockings, or class 3 stockings if response to class 2 stockings is inadequate (see the CKS topic on Venous eczema and lipodermatosclerosis).
    • After deep vein thrombosis (for the prevention of post-thrombotic syndrome) — class 3 stockings, or class 2 stockings if these are poorly tolerated (see the CKS topic on Deep vein thrombosis).
    • Superficial thrombophlebitis — class 1 or 2 stockings (but there is debate about the usefulness of compression for this condition). See the CKS topic on Thrombophlebitis - superficial.
Basis for recommendation
  • For a discussion of the evidence for the use of compression stockings in venous disorders, see the CKS topic on the specific condition being treated.

How do I choose between below knee and thigh length?

  • Below-knee compression stockings are the preferred choice in most people.
  • Consider thigh-length stockings in people with severe varicose veins above the knee or who have swelling which extends above the knee.
Basis for recommendation
  • Below-knee compression is preferred because:
    • Below-knee compression is better tolerated than thigh-length compression, resulting in improved compliance.
    • Below-knee stockings improve the action of the calf-muscle pump, thereby improving venous return from the leg even if venous disease affects the proximal part of the leg.
    • Most randomized controlled trials have used below-knee stockings (for a detailed discussion of the evidence for compression stockings, see the CKS topic on the particular condition being treated).

How do I choose between open and closed toe?

  • The choice mainly depends on the person's preference.
  • Open toe stockings may be preferred for people who:
    • Have arthritic or clawed toes, or fungal infection.
    • Prefer to wear a sock over the compression stocking.
    • Have a long foot size compared with their calf size.
Basis for recommendation

How do I ensure that the stocking fits the person correctly?

  • Measure the person's leg, so that the correct size of stocking can be determined from the manufacturers' sizing charts:
    • If stockings are to be worn on both legs, measure each leg.
    • Write the measurements on the prescription.
    • If these are not stated on the prescription, most pharmacists will carry out the measurements if the person can attend the pharmacy. If this is not possible, they will either ask the person or carer to do the measurements (if capable) or refer the person back to the prescriber.
  • The measurements that need to be taken vary depending on the manufacturer, but in general the following need to be obtained for below-knee stockings (taken with the person seated, and feet flat on the floor):
    • Around the ankle, at the narrowest point just above the ankle bone (malleoli).
    • Around the widest part of the calf (usually the mid-calf area).
    • From the heel to the tip of the longest toe (if a closed-toe stocking is required).
  • If a thigh-length stocking is prescribed, also measure around the widest part of the thigh and from the heel to the buttock fold while the person is standing.
  • If the person has a swollen leg, measurements should be taken first thing in the morning. This may require a visit by a community nurse.
  • Severely swollen legs may first require a period of compression bandaging.
  • Made-to-measure stockings may be required if the person has a deformity affecting the leg or if a correctly sized ready-made stocking cannot be obtained from leg measurements.
Basis for recommendation
  • Compression stockings come in several ready-made sizes; the choice is determined by measuring the person's leg.
  • If stockings are to be worn on both legs, the manufacturers recommend that each leg should be measured to exclude a significant discrepancy in size (in which case, two differently sized stockings will need to be ordered).
  • Occasionally, ready-made stockings are not suitable and a custom-made stocking will be required.
  • Pharmacists can claim a payment for carrying out leg measurements when dispensing compression stockings.

How do I prescribe made-to-measure stockings, if these are required?

  • State 'made to measure' on the prescription.
  • The pharmacist will complete a manufacturer's order form, which will specify the measurements required. If the pharmacist cannot take the measurements, the person may be given the form to be completed by a member of the primary healthcare team.
  • Community nursing teams may be able to order directly from the manufacturer.
  • As with ready-made stockings, if the leg is swollen, measurements are best taken first thing in the morning or after a period of compression bandaging.
Basis for recommendation
  • Made-to-measure stockings require many more measurements to be taken than ready-made stockings. The measurement requirements will vary depending on the manufacturer of the stocking.

Should stockings be removed at bedtime?

  • Compression stockings should generally be taken off at bedtime and put back on first thing in the morning (before any leg swelling develops or worsens).
  • If this is not possible, wear time can be extended up to a maximum of 7 days.
Basis for recommendation
  • Extended wearing of compression stockings is often poorly tolerated, can lead to poor condition of the skin (dryness in particular), and prevents regular application of emollients and other topical treatments (e.g. topical steroids for the treatment of venous eczema) [Wounds UK, 2002]. However, extended wear time may be needed for people who need assistance putting their stockings back on (e.g. by a carer or healthcare professional who can visit only occasionally).

How often should stockings be replaced?

  • Compression stockings should be replaced every 3–6 months.
  • Provide at least two stockings (or two pairs if used on both legs), so that one can be worn while the other is being washed and dried.
  • The stocking should be replaced earlier if any defects or damage become apparent or, if on stretching, the stocking does not return to its original shape.
  • Ideally, each time a stocking is replaced, the leg should be re-measured.
  • The life of the stocking can be prolonged by correct washing. Stockings should be hand washed at about 40°C (a comfortable hand temperature) and dried away from direct heat.
Basis for recommendation
  • These recommendations are based on expert opinion [Johnson, 2002; Wounds UK, 2002] and information on manufacturers' websites.
  • With time, the elasticity of compression stockings will decrease.
  • The size of the leg can change over time (e.g. because of reduction in oedema). Measuring the leg each time a new stocking is dispensed ensures that the person continues to have a properly fitting stocking.
  • High temperatures can damage the elastic in the stocking.

How frequently should a person be reviewed?

  • Review every 3–6 months to:
    • Reassess the condition for which the stocking is being prescribed.
    • Ensure that the person is continuing to wear the stocking successfully and is replacing them regularly.
    • Repeat leg measurements to ensure that the stocking continues to be the correct size.
  • Ideally, Doppler studies should be repeated every 6–12 months or earlier if clinically indicated. Follow local policies, if available.
Basis for recommendation
  • Leg size can change (e.g. because of reduced oedema), and it is therefore important to remeasure the leg at regular intervals to ensure that a correctly fitting stocking is worn [Johnson, 2002; Wounds UK, 2002].
  • Arterial disease may develop in people with venous disease, and significant reductions in ankle-brachial pressure index can occur over a relatively short period (3–12 months) [RCN, 2006]. In practice, the frequency of Doppler assessment will be guided by local availability and resources.

How can I encourage compliance with wearing stockings?

  • Ensure that the person understands the reasons for wearing compression stockings.
  • Ensure that the person has been shown how to put on and take off the stocking. The best time to put stockings on is first thing in the morning, before any leg swelling develops.
  • Check that the person is happy with the colour of the stocking. Men often prefer black or other colours, rather than flesh coloured.
  • Recommend application of an emollient while the stocking is off, to reduce skin dryness and irritation.
  • Ensure that the stocking is a correct fit — if standard sizes are not suitable, the person may need a made-to-measure stocking.
  • If the person is having difficulty tolerating the level of compression, try a lighter compression stocking.
  • If the person is having difficulty using a thigh-length stocking, consider switching to a below-knee stocking (particularly as thigh-length stockings are not usually necessary).
  • If the person is having difficulty putting the stocking on, an application aid may be helpful (information about these can be obtained from the manufacturer of the stocking or from specialist services, such as leg ulcer and lymphoedema clinics).
Basis for recommendation
  • These recommendations are practical suggestions obtained from literature on the use of compression stockings [Johnson, 2002; Wounds UK, 2002] and information on manufacturers' websites.

Prescriptions

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).

Compression stockings: Class 1

Age from 16 years onwards
Class 1 compression stockings: below knee (standard stock)
Compression hosiery class I below knee stocking circular knit standard stock size
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £6.80
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 1 compression stockings: thigh length (standard stock)
Compression hosiery class I thigh length stocking circular knit standard stock size
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £7.44
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 1 compression stockings: below knee (made to measure)
Compression hosiery class I below knee stocking circular knit made to measure
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £23.12
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 1 compression stockings: thigh length (made to measure)
Compression hosiery class I thigh length stocking circular knit made to measure
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £36.95
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.

Compression stockings: Class 2

Age from 16 years onwards
Class 2 compression stockings: below knee (standard stock)
Compression hosiery class II below knee stocking circular knit standard stock size
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £9.94
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 2 compression stockings: thigh length (standard stock)
Compression hosiery class II thigh length stocking circular knit standard stock size
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £11.06
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 2 compression stockings: below knee (made to measure)
Compression hosiery class II below knee stocking circular knit made to measure
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £23.12
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 2 compression stockings: thigh length (made to measure)
Compression hosiery class II thigh length stocking circular knit made to measure
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £36.95
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.

Compression stockings: Class 3

Age from 16 years onwards
Class 3 compression stockings: below knee (standard stock)
Compression hosiery class III below knee stocking circular knit standard stock size
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £11.27
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 3 compression stockings: thigh length (standard stock)
Compression hosiery class III thigh length stocking circular knit standard stock size
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £13.11
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 3 compression stockings: below knee (made to measure)
Compression hosiery class III below knee stocking circular knit made to measure
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £23.12
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.
Class 3 compression stockings: thigh length (made to measure)
Compression hosiery class III thigh length stocking circular knit made to measure
Use as directed. To be measured and fitted by your pharmacist or primary health care provider.
Supply 2 single stockings.
Age: from 16 years onwards
NHS cost: £36.95
Licensed use: yes
Patient information: You can choose to have any of the following types of stockings: stockings with a closed heel and toe, stockings with an open toe, stockings with an open heel and toe. Put the stocking(s) on first thing in the morning and remove before you go to bed.

© NHS Institute for Innovation and Improvement