Hello and welcome. My name is Dot Weir. I'm a nurse and clinician and educator from Holland, Michigan. And I appreciate you spending some time with me today as we talk about an important subject briefly on compression therapy. I appreciate the American Academy of Dermatology inviting me to chat with you about this topic. I often say that edema is the root of many evils. It presents us with known challenges that are related to chronic venous and lymphedema patients, things that we know to look for. But I think often we forget about dependent edema, that patient who doesn't utilize their calf muscle pump, who perhaps is in a wheelchair, spinal cord injured, or that we're keeping off of their feet because of say a diabetic foot ulcer. Edema is edema and it's going to interfere with wound healing and wound repair unless we address it. So we know the one thing that happens with edema is you've got fluid that's going to be out of the ulcer following the path of least resistance as you see in this animated picture right here. And we've, in the dressing lecture, we also described issues with exudate management in terms of wound and perirheum challenges, irritation, erosion of the skin, soiling of clothing and bed linens. It's an embarrassment. It keeps people away from being social. It keeps people out of work. And it's been estimated that about 2 million work days are lost every year in the United States because of edema, because of venous insufficiency and the resulting edema. And then we know also that there is an issue that it can present with oxygen perfusion. When you have capillaries that, when you have tissues that have a lot of edema, the capillaries are going to be farther apart. So the distance that oxygen has to travel or the distance diffusion is going to be increased. So getting that fluid out is going to help to decrease that distance diffusion. So the list of ways that we can manage edema is really relatively short. The choice is going to be driven by why it's there, the etiology or the source of the edema. One thing we can use is negative pressure wound therapy. We don't think too often of negative pressure wound therapy on lower extremity edema. And while it is off-label for the companies that make these devices to suggest that we combine them with compression, many times we do. We use compression wraps. We use compression garments. Certainly leg elevation will help for mild edema, but as soon as that leg goes dependent again, the edema is going to return. Keeping in mind that diuretics, if they have a cardiac reason for that edema, are useful, but they are very rarely a useful tool other than for venous edema or lymphedema. It's just going to make the patient dehydrated as well as can actually make the exudate a little more viscous. Certainly one of the most common reasons for lower extremity edema is chronic venous insufficiency. This is probably the major part of most outpatient ambulatory wound practices. The mechanism of action is pretty well understood. If they have adequate arterial flow, many times what they have is a problem with the return system, the venous return system. With the valves and the veins that are incompetent, they allow for backwashing of the blood into the lower extremity, into the capillary beds. The capillaries become dilated, and when they do, then what happens is they leak fluid, the iron part of the blood called hemocytorin, and they have that chronic look to them. They have the swelling as well as the hemocytorin staining. These types of ulcers represent the majority of most ambulatory care outpatient wound centers, but represent about 60 to 80 percent of all lower extremity ulcerations. Sadly, only 50-60 percent heal by about 12 weeks, and there's a very high recurrence rate because the skin is always going to be vulnerable, and any small injury to the skin can result in the recurrence of an ulcer. The expenditures as far as costs are high, estimated about $34,000 a year or higher, and as I mentioned earlier, in the U.S. it is about 2 million work days are lost every year, but worldwide that number is like 4.6 million. So it's a big problem in all settings, in all countries. Now lymphedema certainly is another very common reason for lower extremity edema. Many times goes unrecognized unless they begin to have a wounding problem, or if they have a very significant lymphatic problem. But what happens normally, this fluid shifts from the arterial system to the venous system, about 10% of that fluid is not reabsorbed. This fluid contains proteins and cellular debris, so the lymphatic system is supposed to capture it, drain it through and filter it in the nodes, and then return it into the vascular system, but this is not always a well-functioning system. So the problem may be primary, a problem with the actual system, or secondary, the system has become damaged and isn't functioning adequately because of surgery, especially groin surgery, hip surgery, knee surgery, obesity, radiation damage, radiation injury, scarring, or some sort of trauma. The best person, the best group to take care of the patient with lymphedema are your certified lymphedema therapists. You can usually find, you can usually talk to your physical therapist in your area and they'll be able to tell you where the lymphedema therapists are located. Now most of these nowadays are physical therapists also, or occupational therapists. So it's, it can be bilateral or it can be unilateral. Most often you'll see this look to the toes. We jokingly call them sausage toes, but they're, that's a very common look to the toes, and I'll show you how you test for lymphedema on the next slide. But again, it's a very common problem best accomplished, or the care best accomplished by someone who's certified in it. They can use manual lymphedema management where they actually manipulate the tissues so that they can move the fluid up the leg, and then followed with bandaging, and then hopefully ultimately with garments that the patients can be prescribed once their lymphedema has become controlled. In the Western world, the most common type of lymphedema though is phlebo-lymphedema. This is mixed etiology because they have chronic insufficient, venous insufficiency. They have fibrotic changes in their tissues because of that, and that impacts the lymphatic system. And what we see people end up with are these very narrow look ankles because of the fibrotic changes, but also very large calves. One of the things that you can test or do to test for the presence of lymphedema is called a stemmer sign. We saw the sausage toes on the previous slide, and this is where we grab the skin actually a little bit lower than this down at the base of the toe, and you're trying to tent it, and if it will not tent, then that is a positive stemmer sign and positive for lymphedema. But at the same time, they have those changes that are more associated with lymphedema, but they also have hemocytoin staining, as well as some of the skin changes, scales, papillomas, and things that we see with both with the chronic venous insufficiency. So as we approach how we're going to manage this edema, regardless of what kind it is, we need to know what the flow is to the to the lower extremities. So getting arterial dopplers, doing arterial ankle brachial indices to look at comparing the arm pressure to the lower extremity pressure in most patients. If they do have diabetes because of the potential for calcified vessels, we would always want to send them to a vascular lab if we can't do this to have their toe pressures measured, because that can vary greatly from their foot pressures if they have calcified vessels. There are very common skin issues that we see with all types of edema. With the venous insufficiency, I think I mentioned already the hemocytoin problem, where the iron carrying part of the blood seeps through the capillaries and stains the tissue, sometimes to a very extreme extent, as you can see in these two. With lymphedema especially, you see these papillomas that they will get on their skin, but I think what is fascinating in these photographs are from a dear friend Susie Eamon, who is a leader in terms of education on lymphedema, and this is after she was working with the patient for three weeks, both with manual lymphatic drainage but also wraps, and you can see the great improvement in the presence of the papillomas just in three weeks time. And then scaling is a big part, but they get this dermatitis or this venous eczema. What you're looking at here, and this drives home the need for good patient education, the patient was diagnosed with venous insufficiency and was put into compression garments, compression stockings, and told that it was a lifetime sentence, that he had to wear these for life. No one told him that he needed to take them off every day. So he came to see us and these garments were actually just grown into his legs, we had to cut them off, but you can see the dry scales, the eczema changes, and then just good skin care and just within a couple of weeks, you can see with good venous wraps, we were able to reduce the edema and through good skin care and descaling, we were able to get rid of those scales and get him on the pathway to his legs closing. Then be able to, one of the challenges is a lot of these people, they go into a venous stocking, compression stock or stocking, and they can't get them on, so they can't get them off either. So we have to find other alternatives, which I'll show you some, something that the patient can manage themselves or at least with a minimum of help from some other person. Now I mentioned the scales and scales need to be removed. They have to be addressed because one of the things that we find, and this is fluorescence imaging, where we use a device that emits a violet light and it will show, because of the violet light, the bacteria that produce porphyrins, gram-positives and gram-negatives generally produce this scarlet color. But this is just showing a scale that I removed and you can see the underneath side of it, there's a lot of bacteria underneath there. So our goal should be to get rid of these scales, because let's face it, if we're going to treat their skin, do we want to treat their skin or do we want to coat something on top of some scales? So we can painstakingly begin to remove those scales and once they're off with good limb hygiene, then we should be able to keep them from reforming. So they have four different looks. I jokingly say like these look like tree bark and you can see I'm just lifting them off and that this is a, this is a, you have to be careful doing this. Obviously you don't want to tear someone's skin, but they can be thickened, they can be dry and flaky, they can be dry and thick, almost plaque-like, and then there are some that are more waxy. But the role is going to be to do good limb hygiene with these folks and teach them good skin care, use good pH balanced soaps, pH balanced moisturizers. And then again, if we need to treat them for the inflammation that's there, if we can get rid of the scales and let's say you're going to use a mid potency steroid topical like triamcinolone for example, then that we'll be able to get to the skin and treat the problem and not just coat on top of the scales. So this is not that time-consuming. What you're looking at here are a few before and after. These are the big plaque ones that I've talked about, very easy to remove before and after. And I hear people say, I don't have time to do that. Well, I was able to get this patient completely descaled. And again, you have to be careful. You're not, you don't want to be tearing their skin and cause them bigger problems. But I was able to get them completely descaled in about eight minutes time. So some of the basics of compression and compression is the application of different types of wraps and stockings, garments, pumps to counteract gravity and assist with that upward flow of the venous blood back up the leg. Helps to, it aids the calf muscle pump. If we have a compression garment or a compression wrap on a patient as they walk, it actually augments the calf muscle pump to again aid in that venous return and reduce the edema. And in the absence of arterial insufficiency, the ideal level of compression to treat a patient with a venous leg ulcer is about 30 to 40 millimeters of mercury. But the choice is going to depend on the evaluation and professional skills of the healthcare provider, as well as the patient's tolerability and the patient's preference. But applying compression is a competency that must be taught with a return demonstration because you can cause injury. As you saw in that patient, just with his garments, just with his compression stocking, but putting wraps on can also cause injury. So we have to be very careful. Now patients don't like these. Encouraging the patient to be accepting of their compression, the best tool that we can use is education. They do need to understand that venous insufficiency is a lifelong disease, not one that they're going to lose their leg over. But they do need to realize that it's just unfortunate, but they're going to need to use some sort of compression or combination of compression for life. Now compression wraps, which I'll show you, are generally short-term so that we can achieve healing of ulcers because many times there's exudates and drainage. And then we can move on to something that's more permanent. For patients to accept them, they have to be comfortable. When we first put them on, it's, we usually try to get to where we're leaving them on for a week. But if we need to bring them in and have a change the wrap in a few days, and I'll get into this more with an example, then so be it. And then we can increase the length of time that they're wearing them as time goes by. So the ideal wraps are ones that are not so bulky, that patients can hopefully wear their own shoes, because patients also need to go to work. They need to be active. And then at the same time, while we're trying to get them to accept this compression, if they're itchy, if their skin feels prickly, they're going to want to remove it. Or if it feels like they're cutting off the circulation or their toes start swelling, there's a different reason. Then patients will cut these off. And actually if their toes are swelling, they need to cut it off. But we need to do everything we can to make their legs, their legs comfortable. And a lot of that is removing the scales and making their skin less itchy. So how do we do this? So change it within three to four days, because what's going to happen is after we put the first wrap on, in about three to four days you will have had probably maximum reduction in volume. And once the volume is reduced that wrap is going to become loose and then it will slide down. And so if patients work wraps, you know, we again as I mentioned we're ultimately trying to get to once a week on these wraps. If their work causes the wrap to become soiled or have an odor like they work outside and landscaping or construction, then many times we change it twice a week. And that's just because of patient acceptance and making them feel clean. One of the things I'll throw in here is every time we change a wrap then we need to perform limb hygiene on these patients. We need to wash their leg because remember it's been covered up with a wrap. So we want to wash their leg for them, moisturize their leg for them, and then put the new wrap on. If the outer wrap is a cohesive bandage, sometimes they can be a little bit sticky. And so some of the kits actually come with a knee-high kind of stocking that you can cover it with so it doesn't stick to everything. But you can also use just like stockinette because if it's sticky at first it'll stick to their clothing, it'll stick to their sheets when they're trying to turn a night and become very frustrating. So and as I mentioned anytime we can we want to have them be able to wear their own shoes. What you see commonly is that people will put a patient into a wrap and then they'll put them into an inexpensive post-op shoe because their shoe did not fit. If we do that then we're actually encouraging the patient to walk flat-footed because of the non-flexibility of a post-op shoe. So they're not then utilizing their calf muscle pump and their lymphedema wrap will not be as effective. So again keeping them in their shoe whenever we can, giving them a shoe cover or something to get home. A lot of people will just buy higher size slippers or crop type shoes to wear while they while they wear the wraps if they can't get into their normal shoes. So I want to tell you a story that sort of illustrates all of this. This was the initial visit for a patient during COVID and he had been seeing a clinic in a town close to us and that had to be closed down because of COVID because of the location of the clinic. So he was referred to us and the gal that sent him to us said, I got to warn you though he will not let you compress him. He just won't. So okay we accepted that until we got the patient in. What you're looking at on that top row is before I cleaned him and the bottom row is after I cleaned him. This gentleman was going through 100 ABD pads a month. He was slathering a zinc paste all over his skin because where you see the back of his leg here and here, that is simply gravity. The drainage was going around to the back and eroding his skin. That's not part of his ulcer. His original ulcers were up in this area. The rest of this is erosion from his exudate. So we chatted with him and said we understand that you don't like compression. He says I can't wear compression. We negotiated with him on a couple of levels. One, we told him you know what if you hate it take it off but we're going to bring you back in just two days and take it off, wash your leg and reapply. And so we worked out a system where he eased into the acceptance of these compression wraps and ultimately he was able to go on in three weeks time. The back of his leg was completely cleared up. We had to work a little bit longer on the actual ulcers but ultimately at ten weeks he was completely closed and you can see he went down two and a half centimeters in his foot, three and a half in his ankle and five centimeters in his calf. So again, easing him into it and working with him and not against him. Finding out what he can tolerate and not making it my way or the highway. Either follow our rules or we can't take care of you. We had to find a way for this to work for him. When we look at the various options that we have for applying compression therapy to lower extremity, we do have choices. There are a variety of brands and types of multi-layer wraps. In our practice and in our hands this is where we start because generally they have drainage, they have ulcers, their volume is going to be going down. We don't want to fit them into a permanent garment, sized garment, until we get their volume down because their size will change. So we use multi-layer wraps until we get the volume down. At the same time we're getting the volume down, the exudate is going to follow the path of least resistance so we may have increased drainage from the ulcer. So we're going to want to use something that we don't we don't mind if we throw it away. We don't care about throwing it away. In fact, we do throw them away. And then we can do limb hygiene every time we change the dressing as I've already mentioned. As the volume reduces and or if they can't come in say often enough to have their wraps changed, then we can put them into something that's more permanent such as compression stockings of which there are a variety, different compression socks. There are nice juxtaposed garments that is because many times these socks and stockings are very difficult to get on. Either because of the patient's body habitus, they may have arthritis in their hands, they can't reach their legs and so they're very difficult to impossible to get on. If they're not going to be able to get them on or off, then they're going to either leave them on for too long or they're not going to wear them at all. So ideally what we have is something that can be easier for the patient to fit into their lifestyle or to have some other person help them to put them on. So there are different kinds of juxtaposed strap devices that enables you to just tighten it up in layers and continue to tighten it as the leg volume goes down. Both of these are covered by Medicare and as of January 1st of last year the Lymphedema Reduction Act, the Lymphedema Act was enacted and so now we can get patients these garments even if they don't have an ulcer. We used to have to wait until they had an ulcer. So those are two very nice options and then lastly there are compression pumps available that if someone has lymphedema or mixed venous and adenoma, phlebo-lymphedema, then the company can work them up to see if their insurance will cover a pump and then they can pump once a day or twice a day and use the pumps in concert with maybe a compression sock or a juxtaposed strap device. Now as we look at focusing in a little bit more on the compression route because this is where we need to focus when we first encounter these patients, there's various types of wraps. So we in venous insufficiency we tend to use disposable wraps. In lymphedema they tend to use reusable wraps that can be washed. So when we talk about the stretch of these wraps, they're talked about in terms of short stretch and long stretch. Now when you get down to the fine science of lymphedema, there are so much information out there about even the threads that those those garments are made up, but I'm sticking with just the wraps at this point in time because that's what I do. So we look at the inelastic or short stretch wraps. These are ones that if you try to pull on them they don't give like an ace wrap. And so they have high dynamic pressures, meaning when you're when that patient's walking because they don't give a lot, they will actually squeeze the leg a little bit more. So it gives a high dynamic pressure, a high pressure when they're walking. And then when they're not walking they have lower pressures. They have high working pressures and low resting pressure. So when they're laying in bed at night or they're sitting and watching TV and they're not walking, it's not going to squeeze them quite as much. So these short stretch have really been shown to reduce edema and leg volume much more rapidly because it affects the supports the calf muscle so much more effectively. Now the elastic or the long stretch have lesser walking pressures and so they're also lesser tolerated resting pressure. So they're squeezing 24-7. So patients aren't as crazy about those. Many times we'll start with a three and these are more your three layer and your four layer wraps. We'll start with those and then graduate them up to a maybe a two layer wrap that short stretch and then they feel so much better and they feel like they're actually getting better. So but they both require and rely on proper competent application and while they can be very safe for the patient, we certainly want to know what we're doing before we put one on. So one of the things that one other thing that we have as an option are just tubular bandages that are various configurations and while this is edema management, it's not really compression. But one way to look at this is that some compression is better than none. So if all they can tolerate is a tubular bandage, you can put them on either as a single layer or a double layer. If that's all they can tolerate, at least that is better than no compression or no elasticity to their leg at all. And these are available, they're disposable ultimately, they can be washed a few times. So it's just a nice alternative to someone who can't either, doesn't qualify for compression wraps, excuse me garments, or simply can't get them on or can't tolerate them. Now the other important thing to remember is that all legs are not created equally, so garments and wraps are not either. What I do want to tell you is that anti-embolism stockings are not appropriate for long-term compression. They're often used, but if you look at these legs, they all are different sizes and shapes, so this kind of care needs to be customized. It can't be an off-the- shelf until you get that volume under control. There are off-the-shelf stockings and socks that can be purchased, but for the most part we're going to need to get the volume down and know that all these legs aren't created equally. So when we're going to order these stockings and things for people, we must get accurate measurements so that their garments can fit appropriately. So for example, this leg is pretty consistent and off the shelf would probably fit that person pretty well. Look at these legs. If they're going to wear a garment, they're going to have to be customized in some way. So again, I encourage you to find a local lymphedema clinic in your area that can help with the management of these very difficult patients. So lastly, just a little trick, because the location of these ulcers and the response to compression and to wraps makes a big difference. And this comes from learnings from our lymphedema colleagues, but one of the trickier areas on the human leg is in this area here, just posterior to the malleolar bones, if you will. Here's the Achilles area, so you know this little dip area. And consequently, many times patients' ulcers are located in this area. And so if you are using a wrap, it's simply going to tent over that area. It's not going to conform to the contour of that ankle. And so one thing to consider is as you are dressing this wound to add some layers of foam. Lymphedema therapists do it all the time to help to conform to very irregularly shaped legs. But adding this foam right over the ulcer can actually increase and normalize those pressures right over those ulcers and be very effective in getting those. So I want to close with an actual case study illustrating just that. This is a patient who had a recurrent ulcer for 25 years, had had the current ulcer for eight months. Now as an aside, if you are seeing someone who has had a recurrent ulcer in the same place for that many years, it would be very prudent to do a biopsy because they could have undergone some some changes that it could actually be a cancer. But in any way, we start seeing this patient and used collagenase to try to clean up some of the necrotic tissue and aborted foam. And while we were doing, we had to treat the periwind skin. You can see this erythema and rash around here. So we were changing it daily so that we could have him treat her, treat her, treat their skin. So I just want to show you the serial progress. So this is when, this is two weeks in. It was, believe it or not, the skin was looking better. So we began to use a two-layer wrap. So then in two weeks time, it's still, the skin was a little better, but the ulcer wasn't looking any better. So at this point in time, we added that layered foam. And you can see just from one week's time of the layered foam, you can see a dramatic improvement in the ulcer bed. This is at day 35, at day 49, and at day 63, she went on to heal. So again, adding compression where it counts. So in closing, how can your patients get these garments? Medicare Part B, the surgical dressing policy, does carry them. If they, if they have pure venous disease, most, but not all, insurance plans will follow the same guidelines. But if they have just pure venous disease, they do not have a lymphatic component documented, then they will have to follow the utilization guidelines for Medicare Part B. So they must currently have an ulcer, and they have to have a venous insufficiency as an ICD-10 diagnosis. You will have to provide some clinical notes to the companies. And so what they do is they give them one pair of stockings per month, or one stocking per leg per month that they have the ulcer on, and then they can get one of those juxtaposed strap garments every six months. So what we want to do is get the volume down as quickly as possible, get their measurements, and then begin to order their stockings. Because if they, if it takes you a couple months to treat the wound, they can get several pairs of stockings in that period of time. And so again, begin as soon as possible to maximize that benefit. I did mention the Lymphedema Treatment Act of 2024. It was effective a year ago, effective January of 24, and it provided coverage of these wraps and garments when there is a diagnosis of lymphedema. And the wonderful thing, and people fought hard for this bill, is that no ulcer is required. Because people who had just straight-out lymphedema were at a huge disadvantage because nothing was covered. And so now the wraps and the garments that are required for pure lymphedema in the absence of an ulcer now are covered. So with that, I thank you for spending some time. I hope I've given you a few little pearls to incorporate into your practice. And again, I appreciate the American Academy of Dermatology allowing me to come and chat with you about this today. Thank you.

edema management

chronic venous insufficiency

lymphedema

compression therapy

patient education

wound healing

lymphatic drainage