Practical Magic: Reducing Slippage of Multilayer Compression Bandages in Patients with a Venous Leg Ulcer and the Typical “Inverted Champagne Bottle” Leg
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Nicholas A. Richmond, BS; Alejandra C. Vivas, MD; Sonia A. Lamel, MD; Liza R. Braun, BA; Robert S. Kirsner, MD
Wound Research Clinic
Department of Dermatology and Cutaneous Surgery
University of Miami Miller School of Medicine
Chronic lipodermatosclerosis (LDS) is a fibrosing condition of the lower leg associated with long-standing venous insufficiency.1 It is characterized by sclerotic, often circumferential, hyperpigmented depressed plaques above the ankle (gaiter area) and often accompanied by proximal concomitant edema. As a result, affected legs are said to have an “inverted champagne bottle” appearance (see Figure 1). LDS is more common in women and individuals with high body mass indexes.2 It frequently precedes the formation of venous leg ulcers (VLUs) and is associated with delayed healing as well.3
VLUs in the setting of LDS can be particularly difficult to treat.4 The gold standard treatment remains graduated compression therapy; however, the characteristic uneven contour of the affected leg poses a challenge to keeping compression bandages in place. Patients experience routine slippage of compression bandages (see Figure 2), which often results in unequal distribution of pressure and may lead to discomfort, pain, trauma to the skin (see Figure 3), and eventual formation of new ulcers. Patient compliance may be affected as a result. Of greatest concern is a potential tourniquet effect caused by excessive pressure exerted over areas of wrinkling, which increases the risk for tissue ischemia. Additionally, compression bandages are thought to confer maximum benefit when applied from the toes to the base of the knee, and therefore may be less effective at healing VLUs as they fall down the lower limb. A modified application of the four-layer elastic bandage system to reduce slippage in VLU patients with LDS is described.
Four-layer compression bandage kits generally include a cotton or wool component intended to be applied as the first layer. This component is soft and maneuverable. We have found that providing additional bulk to the concave region of the leg exhibiting signs of LDS using an additional roll of this layer (see Figure 4) enables the entire compression bandage to stay in place better than traditional methods. In severe cases, additional bulk in the form of abdominal pads (ABD pads) also may be necessary (see Figure 5). Other materials such as gauze and foams can be used as well. The remainder of the bandage should then be applied in a normal fashion see (see Figure 6).
Adding bulk effectively reduces slippage of compression bandages in the setting of LDS. This may improve patient compliance while leading to fewer complications commonly associated with slippage. This method conceivably makes graduated compression more feasible as well. According to LaPlace’s law, sub-bandage pressure is inversely related to the radius of the limb. By creating a more gradual tapering of the leg, compression becomes less variable. Venous ulcers located near bony prominences will likely benefit as well, since they often do not receive sufficient compression.
1. Kirsner RS, Pardes JB, Eaglstein WH, Falanga V. The clinical spectrum of lipodermatosclerosis. J Am Acad Dermatol. 1993;28(4):623–637.
2. Bruce AJ, Bennett DD, Lohse CM, Rooke TW, Davis MD. Lipodermatosclerosis: review of cases evaluated at Mayo Clinic. J Am Acad Dermatol. 2002;46(2):187–192.
3. Moffatt CJ, Doherty DC, Smithdale R, Franks PJ. Clinical predictors of leg ulcer healing. Br J Dermatol. 2010;162(1):51–58.
4. Miteva M, Romanelli P, Kirsner RS. Lipodermatosclerosis. Dermatol Ther. 2010;23(4):375–388.