Wound care is one of the leading expenses for the National Health Service (NHS), with most of this cost associated with non-healing wounds (Guest et al, 2020). Lower limb ulcers are a common non-healing wound, which significantly impact patients’ quality of life (QoL) and often lead to disengagement with treatment (Phillips et al, 2018). Therefore, there is a need for all clinicians to proactively provide optimal and early intervention for the care of people with, or at risk of, non-healing lower limb ulcers.

Optimising holistic care and compression therapy is crucial for patients with venous leg ulcers (VLUs) and chronic oedema/lymphoedema, which can help achieve improved outcomes and save healthcare costs and clinician time. Most lower-limb ulcers are a manifestation of the dysfunction caused by underlying diseases such as venous insufficiency and lymphatic insufficiency. These conditions put people at high risk of developing a lower leg wound (Saghdaoui et al, 2023). 

VLUs account for up to 80% of all lower leg ulcers and can lead to significant pain and risk of infection for the patient (National Institute for Health and Care Excellence [NICE], 2024). Healing rates for patients with a VLU in a community setting have been reported to be as little as 37% at 12 months (Guest et al, 2020), with recurrence rates as high as 50–70% within the first 12 months (Raffetto et al, 2020). The highest rates of recurrence are reported within the first 3 months after healing (Finlayson et al, 2009). Living with a VLU causes emotional and social distress for patients, with patients often facing challenging lifestyle adjustments, and the need for a support network (Guo et al, 2024). Taken together, these issues significantly deteriorate QoL, leading to isolation and depression (Stanek et al, 2023). 

The cornerstone of treatment for patients with a VLU is strong compression therapy of at least 40 mmHg pressure at the ankle (O’Meara et al, 2012). Compression therapy generates external pressure on superficial veins and tissues, thereby assisting venous return, to reduce peripheral oedema and promote wound healing on the lower limb (Nair, 2014). It is important to recognise that compression therapy goes beyond simply reducing venous hypertension and oedema but also plays an important role in reducing inflammation and tissue remodelling (Beidler et al, 2009; Conde Montero et al, 2020). There are decades of evidence in relation to strong compression therapy, with it being proven to decrease time-to-healing and reduce risk of recurrence (O’Meara et al, 2012; Ashby et al, 2014; Webb et al, 2020) while demonstrating statistically significant improvement in healing rates (Shi et al, 2021; Patton et al, 2023).

Despite the wealth of evidence for compression therapy, there are many barriers to timely and sustained application (Atkin et al, 2021). The under-use of compression therapy for venous leg ulceration is a cause for concern and may be linked to other problems including accessing ABPI assessment, lack of confidence in clinical decision making, patient preferences, clinician preferences or product availability (Oates and Adderley, 2019). Additionally, patient adherence is often quoted as a reason for non-application and delayed healing/non-healing (Philips et al, 2018). 

It is important to remember that adherence refers to the degree to which patients concord with prescribed treatment instructions; it encompasses a mutual understanding between healthcare providers and patients regarding treatment and is designed to be non-judgmental, representing a factual observation rather than assigning blame to the patient, healthcare provider or treatment (Weller et al, 2016). Horne et al (2013) indicate that non-adherence might be either purposeful or unintentional. A patient may consciously choose to forgo treatment, leading to deliberate non-adherence. A patient may either misinterpret instructions or neglect a treatment, leading to inadvertent non-adherence. Patients’ perceptions of their condition and related medications/treatments significantly impact adherence (Horne et al, 2013). 

The challenges faced by those living with a VLU can be complex and interrelated, clinicians need to ensure that individual needs are considered and agreed with the patient when setting treatment plans.

There is an urgent need to address unwarranted variation in care, as this offers major opportunities to improve healing rates and thus reduce patient suffering, spending on inappropriate and ineffective treatments and the amount of clinical time spent on wound care (National Wound Care Strategy Programme [NWCSP,] 2023). Timely access to comfortable, easy-to-apply compression therapy with proven efficiency will reduce many of these unwarranted variations of care and outcomes. As the burden of wound care on the NHS continues to grow year on year, NHS services need to turn away from merely managing wounds and instead truly focus on healing wounds (Atkin et al, 2024).

Dr Leanne Atkin PhD MHSc RGN,
Vascular Nurse Consultant 

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