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Compression Therapy to Manage Edema for Patients With Diabetic Ulcers
The use of compression in controlling venous reflux is well known. Less well-known is the use of compression wraps to manage edema associated with diabetic ulcers, which may or may not be combined with venous conditions.1,2 It was estimated that 38% to 55% of patients with diabetic foot ulcers have lymphedema complications.3,4 Among patients with venous leg ulcers, at least 23% to 27% have diabetes.5,6 It is clear there is an overlap between these two types of chronic wounds as they share some common pathophysiologic conditions such as obesity, decreased physical activity, and cardiovascular concerns. The use of compression wraps to control edema and reduce venous congestion could facilitate wound healing by improving microcirculatory skin changes associated with diabetes. Wounds in patients with diabetes have varying degrees of lymphedema related to periwound swelling and glycocalyx dysfunction. According to the International Working Group on Diabetes,7 the use of knee-high offloading boots is also critically important in the treatment of diabetic foot ulcers. Nevertheless, patient presentation with an edematous limb and venous congestion makes the use of an offloading boot difficult and sometimes impossible because of the risk of shearing and skin breakdown.
The availability of a low-profile, two-layer bandage that provides high compression in both layers and is deemed comfortable by patients (Dual Compression System [DCS]; Urgo North America) has made managing edema associated with diabetes quite facile in our clinic. The DCS is unique in that it combines a short-stretch and a long-stretch bandage via novel fabric engineering techniques that provide therapeutic pressure to the lower limb whether the patient is supine or ambulatory.8-12
METHODS
The author presents a case series of patients whose clinical problem of immediate concern was edema associated with diabetic ulcers, which in some cases can prevent the application of the highly recommended total contact cast. The DCS was applied, and patients were monitored for edema reduction via measurements of limb diameter and photographs. Adequate levels of perfusion were established in each case before compression was applied.
Case 1 (Figure 1). A 58-year-old male presented with a right diabetic toe ulcer. In addition to diabetes, other relevant comorbidities included hypertension, coronary artery disease, and previous below-knee amputation of the left lower extremity due to an infected diabetic foot ulcer.
Case 2 (Figure 2). A 53-year-old male had a history of morbid obesity,
pulmonary hypertension, hyperlipidemia, diabetes, venous stasis, and deep vein thrombosis on anticoagulation. He presented with right forefoot ulceration of the distal metatarsal head and second distal toe. He also had a first-toe amputation approximately 8 months before this ulceration.
Case 3 (Figure 3). A 57-year-old female presented with bilateral lower extremity ulcerations: a right distal foot diabetic foot ulcer after first toe and metatarsal resection for toe osteomyelitis and a left distal plantar metatarsal ulceration. Her medical history was
notable for celiac disease, type 2 diabetes, thyroid disease, and hypertension.
RESULTS
Patients reported comfort during the DCS wear period. Edema control was achieved in each case. In case 2, a total contact cast was applied over the bandage, attempting to accomplish both edema and pressure reduction.
DISCUSSION
Edema reduction can aid wound healing in diabetic ulcers. Using compression to achieve this goal is described in the literature but not practiced widely. One concern that the DCS alleviates is the potential reduction of perfusion to harmful levels due to improper wrapping of the bandage. For this reason, a proper assessment of lower extremity perfusion must be done. The safety data and the presence of the visual pressure indicator significantly increases the confidence for application of the compression therapy in the actual intended pressure target range and minimizes the risk of harm due to overcompression.
REFERENCES
1. Wu SC, Crews RT, Skratsky M, et al. Control of lower extremity edema in patients with diabetes: double blind randomized controlled trial assessing the efficacy of mild compression diabetic socks. Diabetes Res Clin Pract. 2017;127:35-43. doi:10.1016/j.diabres.2017.02.025
2. Bowering CK. Use of layered compression bandages in diabetic patients. Experience in patients with lower leg ulceration, peripheral edema, and features of venous and arterial disease. Adv Wound Care. 1998;11(3):
129-135.
3. Apelqvist J, Larsson J, Agardh CD. The importance of peripheral pulses, peripheral oedema and local pain for the outcome of diabetic foot ulcers. Diabet Med. 1990;7(7):590-594. doi:10.1111/j.1464-5491.1990.tb01454.x
4. Ho TK, Leigh RD, Tsui J. Diabetic foot disease and oedema. Br J Diabetes Vasc Dis. 2013;13(1):45-50.
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7. Bus SA, Armstrong DG, Gooday C, et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update). Diab Metab Res Rev. 2020;36(suppl 1):e3274. doi:10.1002/dmrr.3274.
8. Benigni JP, Lazareth I, Parpex P, et al. Efficacy, safety and acceptability of a new two-layer bandage system for venous leg ulcers. J Wound Care. 2007;16(9):
385-390. doi:10.12968 jowc.2007.16.9.27866
9. Hanna R, Bohbot S, Connolly N. A comparison of inferface pressures of three compression bandage systems. Br J Nurs. 2008;17(20):S16-24. doi:10.12968/bjon.2008.17.Sup9.31661
10. Jünger M, Ladwig A, Bohbot S, Haase H. Comparison of interface pressures of three compression bandaging systems used on healthy volunteers. J Wound Care. 2009;18(11):474, 476-80.
11. Lantis JC 2nd, Barrett C, Couch KS, et al. A dual compression system: preliminary clinical insights from the US. J Wound Care. 2020;29(suppl 9):S29-S37. doi:10.12968/jowc.2020.29.Sup9.S29
12. Lazareth I, Moffatt C, Dissemond J, et al. Efficacy of two compression systems in the management of VLUs: results of a European RCT. J Wound Care. 2012;21(11):
553-4, 556, 558 passim. doi:10.12968/jowc.2012.21.11.553
Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process and is based on a poster presented at the Symposium for Advanced Wound Care, Spring 2022.
