Previous changes

April 2026 — reviewed. A literature search was conducted in April 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. The topic has been aligned with the 2020 National Wound Care Strategy Programme consensus document Recommendations for lower limb ulcers, the 2021 Wounds UK Best practice statement Compression hosiery; a patient-centric approach, the 2023 Wounds UK Best Practice Statement The use of compression therapy for peripheral oedema: considerations in people with heart failure, and the 2025 Wounds UK guidance Compression hosiery for the prevention of recurrent leg ulceration: Evidence, efficacy and best practice.

March 2026 — minor update. Minor update to assessment section.

February 2026 — minor update. Minor update to assessment section.

May 2022 — reviewed. A literature search was conducted in April 2022 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. Updated literature has been incorporated to provide supporting evidence for the guidance. No major changes to the clinical recommendations have been made.

September 2018 — minor update. Changes made to recommendations on the use of elastic graduated compression stockings to prevent post-thrombotic syndrome or VTE recurrence after a proximal DVT to align with NICE guideline CG144.

September to October 2017 — reviewed. A literature search was conducted in September 2017 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. 

May 2014 — minor update. Minor change to text to clarify interpretation of ankle-brachial pressure index measurements in Assessment section.

September 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. No changes to clinical recommendations have been made.

June 2010 — minor update. The recommendation on the class of compression stockings to use to prevent the recurrence of deep vein thrombosis, or the development of post-thrombotic syndrome, has been updated.

July to October 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 April 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 April 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 April 2026.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 April 2026.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 April 2026.

New policies

No new national policies or guidelines since 1 April 2026.

New safety alerts

No new safety alerts since 1 April 2026.

Changes in product availability

No changes in product availability since 1 April 2026.

What assessment should I carry out before prescribing compression therapy?

• Carry out a full lower‑limb assessment before prescribing compression therapy, including consideration of red flags, assessment of arterial supply, venous disease, limb shape, and skin condition.
• Assess for possible peripheral arterial disease (PAD) by:
  • Asking about risk factors for PAD including the person's smoking status and comorbidities (such as diabetes, cardiovascular events, hypertension, hyperlipidaemia, chronic kidney disease), as well as family history of PAD.
  • Reviewing the person's surgical history for any arterial or venous interventions.
  • Reviewing the person's current medication (for example, angiotensin-converting enzyme (ACE) inhibitors, immunosuppressants, or corticosteroids).
  • Asking about the presence and severity of possible symptoms of intermittent claudication (such as muscle pain and fatigue in the buttock, thigh, calf or ankle, which occurs during exercise, and is relieved by rest) and critical limb ischaemia (such as intense leg or foot pain when resting). Be aware that critical limb ischaemia can also be suggested by ulceration.
  • Checking the femoral, popliteal, and foot pulses.
• Measure ankle-brachial pressure index (ABPI) using Doppler assessment to help identify peripheral arterial disease.
  • ABPI should be interpreted alongside clinical findings, as it may be unreliable in people with diabetes, chronic oedema, lymphoedema, or arterial calcification.
    • Toe-brachial pressure index (TBPI) or Doppler waveform analysis may be required when ABPI is unreliable.
  • Use the following thresholds to guide compression therapy:
    
    • ABPI less than 0.5  — severe arterial insufficiency is likely. Compression therapy is contraindicated. Urgent vascular assessment is required.
    • ABPI 0.5–0.79  — mixed arterial and venous disease is likely. Modified or light compression may be used with caution, supported by clinical monitoring and specialist advice where needed.
    • ABPI 0.8–1.3 — no significant arterial disease. Full compression therapy is generally considered safe.
    • ABPI greater than 1.3–1.4 — arteries may be calcified and incompressible. ABPI is unreliable. Further vascular assessment (for example, TBPI) is required before prescribing compression.
    • Note: ABPI is not required before initiating light compression - 20 mmHg (for example, Class 1 stockings) when no red flags for arterial disease are present.
• Assess the legs for possible venous disease:
  • May be suggested by varicose veins, venous dermatitis, haemosiderin deposition (brawny oedema), lipodermatosclerosis, atrophie blanche, and healed or active venous ulcers. 
• Also examine the skin for signs of fragility, dermatitis, infection, or wounds.
• Assess limb shape, oedema, and tissue quality to determine the most appropriate compression system.
  • People with significant oedema, limb distortion, or deep skin folds may require flat‑knit garments, adjustable compression wraps, or bandaging, rather than standard circular‑knit stockings.
• Assess the person’s ability to apply and remove compression.
  • Conditions such as arthritis, reduced hand strength, or limited mobility may make it difficult to manage stockings independently.
  • Donning aids, alternative garment types, or support from carers may be required.
• Compression therapy should be delayed and further assessment/appropriate specialist referral undertaken if any of the following are present:
  
  • Suspected acute or chronic limb ischaemia.
  • Acute or rapidly worsening infection of leg or foot (suggested by unilateral redness, swelling, pain, pus, heat).
  • Symptoms of sepsis.
  • Suspected deep vein thrombosis (compression may be used once pain allows, diagnosis is confirmed and treatment has been started).
  • Acute decompensated heart failure.
  • Suspected skin cancer.

How should I choose the most appropriate compression system?

• Ensure that the compression system is chosen in collaboration with the person through a shared decision-making process.
• Choose an appropriate compression system based on the person's underlying condition, limb shape, oedema, skin condition, ability to apply the device, and personal preference.
  • Be aware that compression up to 20 mmHg can be applied without any form of arterial assessment if there are no red flags.
• Options include:
  • Compression stockings (British Standard or RAL).
  • Hosiery kits, consisting of two compression garments worn one over the other (for venous leg ulcer healing).
  • Adjustable compression wraps (useful for fluctuating oedema or self‑management).
  • Multilayer bandaging systems (for oedematous or distorted limbs).
  • Flat‑knit garments (for lymphoedema or chronic oedema).
• Consider how the choice of compression product might affect the person's quality of life, including:
  • Ability to complete activities of daily living
  • Adherence to the treatment regimen
  • Physical health, including whether they can apply products themselves
  • Mental health and wellbeing
  • Relationships with others, including whether they have informal carer support at home
• Select the degree of compression:
  • This should be guided by the person's underlying condition (see below), but may need to be reduced to the highest level the person can tolerate safely.
  • Increase compression strength gradually if needed.
  • Reduce compression if pain, numbness, or skin damage occurs.
• Use mild compression (Class 1; 14–17 mmHg) for:
  • Mild venous symptoms.
  • People unable to tolerate higher compression.
  • Superficial vein thrombosis when Class 2 is painful.
    • For more information, see the CKS topic on Superficial vein thrombosis (superficial thrombophlebitis)
  • Initial management when ABPI is borderline, or the person is awaiting further vascular assessment.
  • Varicose veins with symptoms.
    • Note: compression therapy is not a first-line treatment for varicose veins and should only be offered if interventional treatment is unsuitable, such as during pregnancy.
    • For more information, see the CKS topic on Varicose veins
  • Venous eczema.
  • Lipodermatosclerosis.
    • For more information, see the CKS topics on Varicose veins, Venous eczema and lipodermatosclerosis
• Use moderate compression (Class 2; 18–24 mmHg) for:
  • Atrophie blanche.
  • Most cases of superficial vein thrombosis.
    • For more information, see the CKS topic on Superficial vein thrombosis (superficial thrombophlebitis)
  • Mild to moderate oedema where stronger compression is not required or not tolerated.
• Use strong compression (Class 3; 25–35 mmHg) for:
  • Severe venous insufficiency.
  • Healing of venous leg ulcers (therapeutic dose is > 40 mmHg).
  • Prevention of venous ulcer recurrence.
  • Persistent venous eczema or lipodermatosclerosis not controlled with Class 2.
  • Post‑thrombotic syndrome.
  • Mild to moderate oedema requiring stronger compression
  • Chronic oedema/lymphoedema.
• Refer to a specialist service for initiation of high‑stiffness compression systems for people with:
  • Chronic oedema/lymphoedema requiring stronger containment.
  • Chronic oedema with fibrosis.
  • Limb‑shape distortion.
  • Deep skin folds.
  • Rapidly fluctuating oedema (adjustable wraps may be required).
    • Note: the most appropriate specialist service for referral may vary locally.
• Use below‑knee garments for most venous and lymphatic conditions.
• Use thigh‑length garments (or tights) only when swelling or varicosities extend above the knee.
• Select toe style based on need:
  • Use open‑toe garments for toe deformities, fungal infection, long foot length, or when socks are required over the stocking.
  • Use closed‑toe garments for comfort and warmth where no contraindications exist (such as diabetic neuropathy).
• Provide at least two garments (or two pairs if used on both legs), so that one can be worn while the other is being washed and dried.
• Ensure that compression garments are replaced every 3–6 months, or sooner if any stretching, defects, or damage become apparent.

How do I ensure that the stocking fits the person correctly?

• The efficacy of compression stockings is reliant on ensuring the person's leg is accurately measured and that garments are fitted correctly.
• Compression stockings are available in several ready-made sizes — the choice is determined by measuring the person's leg.
  • This can be undertaken in the pharmacy when dispensing a prescription for compression stockings (a payment can be claimed for this service).
  • If this is not possible, the person or their carer may be asked to take the measurements (if capable), or the person should be referred back to the prescriber for alternative arrangements to be made.
• In general, when measuring the person:
  • If stockings are to be worn on both legs, measure each leg to exclude a significant discrepancy in size (in which case, two differently sized stockings will need to be ordered).
  • Take measurements directly against the skin to ensure accuracy. Using a skin marker may help to ensure accuracy through re-checking measurements. 
  • Measurements that need to be taken vary depending on the stocking manufacturer (specific measuring guides are available), but in general, the following need to be obtained for below-knee stockings (taken with the person seated, and feet flat on the floor):
    • Circumference of the ankle, at the narrowest point just above the ankle bone (malleoli).
    • Circumference of the widest part of the calf (usually the mid-calf area).
    • Length of the foot from the heel to the tip of the longest toe (if a closed-toe stocking is required).
  • If a thigh-length stocking is prescribed, also measure around the widest part of the thigh.
  • If the person has a swollen leg, measurements should be taken first thing in the morning — this may require a visit by a community nurse.
  • If the person has skin folds due to oedema or the limb is particularly misshapen, specialist assessment may be required.
  • Severely swollen legs may first require a period of compression bandaging.
• Made-to-measure stockings may be required if the person has a deformity affecting the leg or if a correctly sized ready-made stocking cannot be obtained based on the leg measurements. State 'made to measure' on the prescription.
  
  • Note: If a pharmacist, on measuring a person for ready-made stockings, identifies that a made-to-measure stocking is required, they can endorse the prescription with 'made to measure' and be reimbursed appropriately.
  • The pharmacist will complete a manufacturer's order form, which will specify the measurements required. If the pharmacist cannot take the measurements (for example, the person is unable to attend the pharmacy), a member of the primary healthcare team may need to measure the person.
  • As with ready-made stockings, if the leg is swollen, measurements are best taken first thing in the morning or after a period of compression bandaging.
• Ideally, each time a stocking is replaced, the leg should be re-measured.

What information and advice should I offer?

• Ensure that the person knows:
  • The reasons for, and the benefits of, wearing compression garments.
  • How to put on and remove the garment, and is able to do so.
    • If the person is having difficulty, an application aid can be prescribed (for example, ActiGlide®).
  • That the best time to apply compression is first thing in the morning, before any leg swelling develops.
  • When and how to reorder their compression garments.
  • When to seek medical advice.
• Check that the person is satisfied with:
  • The fit — if standard sizes are not suitable, a made-to-measure garment may be needed.
  • The level of compression — if the person cannot tolerate the level of compression, consider reducing the strength.
  • The length — if the person is having difficulty using a thigh-length garment, consider switching to a below-knee garment (thigh-length garments are not usually necessary unless there are severe varicose veins above the knee, or there is swelling which extends above the knee).
  • The colour of the garment.
• Advise that:
  • The compression garment should be taken off at bedtime unless continuous use has been specifically advised as part of a structured management plan, such as in lymphoedema care.
  • An emollient should be applied while the garment is off, to reduce skin dryness and irritation.
  • The person should be offered regular review, with the garment replaced every 3–6 months to ensure continued good fit and the correct level of compression.
  • The garment should be replaced sooner if any stretching, defects, or damage become apparent.
  • The life of the garment can be prolonged by correct washing. For example, stockings should be hand-washed at about 40°C (a comfortable hand temperature) and dried away from direct heat.
• If adherence to treatment is an issue, consider discussing with the person that:
  • Compression is a long-term therapy that could be viewed in the same way as long-term drug treatment.
  • Compromise between the person's preference and clinical need may be required.
  • Lower compression can be used if high compression is not initially tolerated.
  • As tolerance builds over time, compression levels may be increased
  •  Factors that make compression more tolerable may include skin care, elevation, activity, weight loss, and access to support groups.

How frequently should a person be reviewed?

• Review every 3–6 months to:
  • Reassess the condition for which compression therapy is being prescribed.
  • Ensure that the person is continuing to wear the compression device successfully and is replacing it regularly.
• Ask the person to wear their compression device for the review appointment, so that the fit can be re-evaluated.
  • Repeat leg measurements to ensure continued correct fit.
  • Assess the fit – the device should not feel loose, and the fabric should be evenly distributed. Knee-length systems should sit two fingers’ width below the knee crease, and thigh-length systems should sit four fingers’ width below the gluteal fold. Material should not pinch the skin or cause pain.
• Review people with neuropathy, frailty, or fragile skin on a more regular basis, with an appropriate interval determined by clinical judgement
• Ideally, Doppler studies should be repeated every 6–12 months or earlier if clinically indicated. Follow local policies, if available.