What dressing should be used under compression bandages or does it not matter?
I once worked with a dermatology consultant who said you could use newspaper as a dressing on leg ulcers for all she cared as long as the compression bandaging was in place correctly. While I would not advocate using newspaper on any wound under any circumstances, she did have a point about the compression. Graduated compression bandaging is the mainstay of treatment for venous leg ulcers (VLUs), the most common leg ulcer aetiology (Nelzen et al, 1994).
Venous leg ulcers
VLUs occur as a consequence of damaged valves in the veins of the lower leg (Palfreyman et al, 2006). Valve damage, by deep vein thrombosis for example, causes ‘pooling’ of deoxygenated blood in the lower venous system which increases venous pressure (venous hypertension) in the superficial veins. Over time this results in a pre-disposition to ulceration.
Compression bandaging aids venous return by compensating for the inefficient valve function. Improved venous return reduces tissue oedema and congestion; allowing oxygenated blood through to the wound bed and facilitating the removal of harmful by-products of metabolism. As fluid is reabsorbed into the venous system exudate levels diminish and with them the damaging effects of chronic wound fluid on the ulcer bed and surrounding tissue. All these factors contribute to a healthy wound bed. As a result compression systems can improve ulcer healing rates significantly (O’Meara et al, 2009) and are therefore a critical component of effective leg ulcer management. However, the choice of dressing used is an important consideration.
Types of dressings
A systematic review considered the effectiveness of wound dressings for VLUs and found no evidence to suggest that one dressing type was better than another in terms of ulcers healed, including notably, the use of cheaper low-adherent dressings (Palfreyman et al, 2006).
More recently, a review of honey under compression suggested that despite being an increasingly popular choice in leg ulcer management, honey dressings as an adjuvant to compression do not significantly increase leg ulcer healing either (Jull et al, 2008). In the absence of evidence to the contrary, clinical guidelines for leg ulcer management suggest dressings for leg ulcers should be low adherent, low cost and acceptable to the patient (RCN, 2006).
However, there are some fundamental principles of wound care that apply whatever the wound aetiology. These include: preparation of the wound bed for healing through control of moisture levels; removal of non-viable tissue; and management of excess bio-burden (Schultz et al, 2003). Where compression alone is insufficient, absorptive dressings, such as foams, alginates and hydrofibres, will aid in the removal of excess exudate, while the use of fluid donating dressings, such as hydrogels and hydrocolloids, on drier wounds will provide the necessary moisture levels for removal of non-viable tissue through autolysis. When infection arises the use of antimicrobial dressings may be necessary to reduce wound bio-burden. Silver, iodine and honey have all been shown to be effective antimicrobial agents, although dressing choice must be based on individual patient need with factors such as microbial sensitivity and therapeutic effect taken into account.
Other principles such as the non-traumatic removal of dressings and minimisation of patient discomfort must also be considered in dressing selection. A study comparing efficacy of two hydrocolloid dressings under compression found little difference between the two, although in terms of pain on removal one (Urgotul, Urgo), was considered superior (Meaume et al, 2005). Similarly, foam composite dressings have been found to result in significant improvements in peri-wound skin condition when compared with hydrocellular foam dressings (Vanscheidt et al, 2004). These factors, while not directly related to ulcer healing, do impact on quality of life, an important principle of effective leg ulcer management. For this reason the use of a pain relieving dressing such as Ibu (Coloplast), which delivers NSAIDs to the ulcerated area topically, can also improve the day-to-day experience of living with a VLU.
The dressing’s ability to function effectively under the compression is also a factor to be considered. A dressing that relies on vapour transmission and evaporation through the outer layer to manage exudate effectively may be significantly compromised under a bandage system. Conversely, a large, bulky dressing can compromise the effectiveness of bandage function as direct compression over the ulcer bed is diminished. In addition dressings with bulky ‘edges’ can result in raised pressure points and further tissue damage. Always check with the manufacturers as to whether your choice of dressing is known to work effectively under compression or not. If the function of either compression or dressing is compromised then optimal healing cannot be achieved.
The choice of dressing under compression does matter. Fundamental principles of wound care still apply but must be considered in the context of the underlying aetiology and the role of compression bandaging. As for newspaper dressings, they’re a definite no, no.
Julie Vuolo, MA, BA, PGDip Ed., Dip(TV), RN, is senior lecturer tissue viability and link lecturer, East and North Hertfordshire PCT, University of Hertfordshire.
Jull, A.B. et al (2008) Honey as a Topical Treatment for Wounds. Cochrane Database of Systematic Reviews. Issue 4. Art. No. CD005083
Meaume, S. et al (2005) Evaluation of a lipidocolloid wound dressing in the local management of leg ulcers. Journal of Wound Care; 14: 7, 331-336.
Nelzen, O. et al (1994) Venous and non venous leg ulcers: clinical history and appearance in a population study. British Journal of Surgery; 81: 182-187.
O’Meara, S. et al (2009) Compression for Venous Leg Ulcers. Cochrane Database of Systematic Reviews. Issue 1. Art. No. CD000265
Palfreyman, S.S.J. et al (2006) Dressings for Healing Venous Leg Ulcers. Cochrane Database of Systematic Reviews. Issue 3. Art. No.:CD001103.
RCN (2006) The Nursing Management of Patients with Venous Leg Ulcers. London: RCN.
Schultz, G.S. et al (2003) Wound bed preparation: a systematic approach to wound management. Wound Repairand Regeneration; 11: s1, 1-28.
Vanscheidt, W. et al (2004) Comparing a foam composite to a hydrocellular foam dressing in the management of venous leg ulcers: a controlled clinical study. Ostomy Wound Management; 50: 11, 42-55.