Compression hosiery formulary

A comprehensive medical and social history should be undertaken with all patients regardless of vascular status (NWCSP, 2020).

Before prescribing compression hosiery, the patient should be assessed for the following:

• Absent foot pulses, or diminished compared with other side
• Poor capillary refill – should be less than 3 seconds
• Cold leg and/or foot when compared with the other side
• Painful cramping in calf muscles brought on by activity, such as walking or climbing stairs (intermittent claudication) and relieved by rest
• Obvious lower limb ischaemia, especially rest pain and/or gangrene/ ischaemic ulceration.

If any one or more of these is present, the calculation of an Ankle Brachial Pressure Index (ABPI) may be considered necessary.  Those patients with suspected peripheral arterial disease should be referred to the vascular department for assessment.  It is important to be aware that an ABPI can only be recorded accurately in a non-oedematous limb, therefore it may be necessary to apply 20mmHg compression to reduce the swelling before undertaking ABPI measurement (NWCSP, 2020).

The condition of the skin must be considered as fragile skin may be damaged whilst donning or doffing compression hosiery.  Dexterity and the ability of the patient to reach their feet must also be considered, appropriate donning aids and/or assistance arranged if necessary.  A wrapping device may be more appropriate in these instances.

• Choice of garment depends on the individual circumstances of each patient, eg dexterity, ability to reach feet, availability of assistance, and condition of skin.
• Circular knit hosiery is not suitable for limbs with skin folds, eg at ankle or knee, as these garments will create a tourniquet effect in the skin folds.
• Most patients will be suitable for a below knee option but thigh-length stockings or tights are required for oedema that extends to the thigh and groin area.
• Most patients will be suitable for stock size, however made to measure garments are required for those with disproportionate limbs, skin folds, or severe oedema/lymphoedema with skin changes.
• Scrupulous washing and drying of the skin followed by moisturising is required at each stocking change.
• Ensure folds and creases in the garment are smoothed out during application and wear to prevent pressure damage.
• Hosiery should usually be removed at night and applied first thing in the morning. If oedema reoccurs overnight (rebound oedema), garments may be worn at night.  In patients who cannot apply the garment without assistance and rely on health and social care services to assist them, it can be left on for up to three days.
• Application aids may be required to assist self management and should be offered to all patients.
• Hosiery should be washed in mild detergent and hung dried.  Fabric softener should not be used.  Most garments can be washed on a cool (30⁰C) cycle.  A spin cycle can be used to assist drying if washing by hand.  Some garments can be tumble-dried on low setting but check manufacturers’ instructions.
• RAL classes of hosiery should be renewed every six months or earlier if damaged, eg ladders, holes.  The compression in British Standard class hosiery is only guaranteed for three months.  If the stockings are effective and remain a good fit, repeat garments can be prescribed without the need for further measurement.
• British Standard Class 1 Hosiery can be bought over the counter; however patients should not be commenced in any hosiery with higher compression capabilities without full holistic assessment.

Uncheck the formulary box, then input the manufacturer name, range, class, type of garment, size and colour eg Jobst opaque, Class 2, Tights, Closed toe, Size VI, Black.  For custom fit garments use the manufacturers codes provided, several codes may be required.

Uncheck the formulary box, then input the manufacture name, range, class, colour, length, garment type, toe, size eg  Juzo Dynamic Class 3 Black Standard Thigh High Closed Toe Size IV.  For custom fit garments use the manufacturers codes provided, several codes may be required.

BLS, (2021), Assessing vascular status in the presence of chronic oedema prior to the application of compression hosiery, British Lymphology Society 

NWCSP, (2020), Lower limb: Recommendations for clinical care, National Wound Care Strategy Programme

Neill K, Turnbull K, (2012) Use of specialist knowledge and experience to manage patients with mixed aetiology ulcers, Journal of Wound Care 21 (4), pp168-174

Best Practice Statement: Compression Hosiery: A Patient-Centric Approach (3^rd Edition), (2021) Wounds UK

* Stemmer’s sign is considered as diagnostic of lymphoedema / chronic oedema.  A positive Stemmer’s sign is the inability to pinch the skin at the base of the second toe due to oedema and fibrosis

Category 1: British Standard: Is made from light, thin fabric in a circular knit. It is suitable to manage symptoms of chronic venous insufficiency and prevent venous ulcer and ulcer recurrence in the absence of oedema in a normal shape limb.

Can be used for  palliative patients (Class 1), elderly patients (Class I) and as low compression option for venous oedema

Duomed Soft should be used instead of other British standard hosiery such as Scholl

Category 2: European/RAL Standard Circular Knit: Is made from stiffer yarn. It is suitable to manage symptoms of chronic venous insufficiency and prevent venous ulcer and ulcer recurrence in the presence of oedema/lymphoedema. It is only suitable for use in a normal shape limb, ie no skin folds or oedema that is greater in one part of the limb such as around the ankle.

Category 3: European/RAL Flat Knit: is made from a stiffer yarn knitted into a flat piece of fabric that is stitched together by a seam. It is suitable for disproportionate limbs with skin folds and patients with severe chronic oedema and lymphoedema. It is available in class 1 (18-21mmHg), class 2 (23-32mmHg) and class 3 (34-46mmHg). Higher classes and more complex garments are available for specialist use, contact Highland Lymphoedema Service for advice High-UHB.highland-lymphoedema@nhs.net.

Category 4: inelastic adjustable compression garments: These garments provide an effective alternative for patients who are able to self manage their care, those with rebound oedema when changed to stockings and for those with fragile skin or dexterity problems.

Dressings can be applied below these garments offering an effective alternative to bandaging (Damstra & Partsch, 2015). They are useful in ensuring consistency of sub-garment pressure in settings where several carers may be involved in the application of compression.

Despite their relatively high initial cost there is evidence that they can be a cost effective alternative to bandaging when nursing time and the cost of bandages is taken into consideration (Williams, 2016). They are supplied with a liner stocking.

Category 5: Leg Ulcer Hosiery Kits: Although compression bandages are the recommended first line treatment for venous leg ulcers, hosiery kits provide a useful alternative in patients who prefer to self manage their care. They are recommended for the management of venous ulcers after oedema reduction and for helping to prevent the recurrence of such ulcers for people who may otherwise have difficulty in donning garments as they comprise two components which together provide a nominal compression of 40mmHg at the ankle with a decreasing gradient from distal to proximal. Separate liner packs are available.

For use following full patient assessment.