Compression hosiery formulary: Highland HSCP only (Formularies)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Purpose:

To support the effective management of patients affected by chronic oedema and/or lymphoedema.
Compression hosiery is used for the management of venous and lymphatic disorders by helping to minimise swelling and aid the flow of blood and lymph (Neil & Turnbull, 2012).

This formulary is for any health practitioner who recommends or prescribes compression garments. It should be used for any patient who requires compression garments as it includes all compression garments/hosiery that is used to treat a wide range of conditions:

  • Venous leg ulcers
  • Chronic venous insufficiency
  • Lymphoedema, primary and secondary
  • Dependency oedema
  • Venous oedema
  • Lipoedema
  • Other types of chronic oedema (oedema > 3 months)

Compression hosiery is not the same as anti-embolism stockings and each have a specific clinical role. Anti-embolism stockings are not intended for long term use.

Assessment

A comprehensive medical and social history should be undertaken with all patients regardless of vascular status (NWCSP, 2020).

Before prescribing compression hosiery, the patient should be assessed for the following:

  • Absent foot pulses, or diminished compared with other side
  • Poor capillary refill – should be less than 3 seconds
  • Cold leg and/or foot when compared with the other side
  • Painful cramping in calf muscles brought on by activity, such as walking or climbing stairs (intermittent claudication) and relieved by rest
  • Obvious lower limb ischaemia, especially rest pain and/or gangrene/ ischaemic ulceration.

If any one or more of these is present, the calculation of an Ankle Brachial Pressure Index (ABPI) may be considered necessary.  Those patients with suspected peripheral arterial disease should be referred to the vascular department for assessment.  It is important to be aware that an ABPI can only be recorded accurately in a non-oedematous limb, therefore it may be necessary to apply 20mmHg compression to reduce the swelling before undertaking ABPI measurement (NWCSP, 2020).

The condition of the skin must be considered as fragile skin may be damaged whilst donning or doffing compression hosiery.  Dexterity and the ability of the patient to reach their feet must also be considered, appropriate donning aids and/or assistance arranged if necessary.  A wrapping device may be more appropriate in these instances.

General hosiery considerations

  • Choice of garment depends on the individual circumstances of each patient, eg dexterity, ability to reach feet, availability of assistance, and condition of skin.
  • Circular knit hosiery is not suitable for limbs with skin folds, eg at ankle or knee, as these garments will create a tourniquet effect in the skin folds.
  • Most patients will be suitable for a below knee option but thigh-length stockings or tights are required for oedema that extends to the thigh and groin area.
  • Most patients will be suitable for stock size, however made to measure garments are required for those with disproportionate limbs, skin folds, or severe oedema/lymphoedema with skin changes.
  • Scrupulous washing and drying of the skin followed by moisturising is required at each stocking change.
  • Ensure folds and creases in the garment are smoothed out during application and wear to prevent pressure damage.
  • Hosiery should usually be removed at night and applied first thing in the morning. If oedema reoccurs overnight (rebound oedema), garments may be worn at night.  In patients who cannot apply the garment without assistance and rely on health and social care services to assist them, it can be left on for up to three days.
  • Application aids may be required to assist self management and should be offered to all patients.
  • Hosiery should be washed in mild detergent and hung dried.  Fabric softener should not be used.  Most garments can be washed on a cool (30⁰C) cycle.  A spin cycle can be used to assist drying if washing by hand.  Some garments can be tumble-dried on low setting but check manufacturers’ instructions.
  • RAL classes of hosiery should be renewed every six months or earlier if damaged, eg ladders, holes.  The compression in British Standard class hosiery is only guaranteed for three months.  If the stockings are effective and remain a good fit, repeat garments can be prescribed without the need for further measurement.
  • British Standard Class 1 Hosiery can be bought over the counter; however patients should not be commenced in any hosiery with higher compression capabilities without full holistic assessment.

Tips for searching for lymphoedema garments using Vision and EMIS

Vision

Uncheck the formulary box, then input the manufacturer name, range, class, type of garment, size and colour eg Jobst opaque, Class 2, Tights, Closed toe, Size VI, Black.  For custom fit garments use the manufacturers codes provided, several codes may be required.

EMIS

Uncheck the formulary box, then input the manufacture name, range, class, colour, length, garment type, toe, size eg  Juzo Dynamic Class 3 Black Standard Thigh High Closed Toe Size IV.  For custom fit garments use the manufacturers codes provided, several codes may be required.

Choice of prescribable garments in presence of chronic oedema in lower limb

Assess texture of tissues and choose appropriate texture of garment

Texture of tissues

Type of garment

Prescribable  garments

Watery

Soft, easily pits, rebound <30 seconds

Negative Stemmer’s sign *

 

Elastic

Stretchy and gives sustained pressure even at rest but lower containment capability

Wide range of ‘off the shelf’ garments

Circular knit garment  (do not use in presence of skin folds)

Adjustable wraps are useful over wound dressings and can accommodate reduction in girth.

British standard

  • Medi Duomed Soft

RAL standard – class 1

  • Jobst Opaque
  • Mediven for men
  • Mediven Active
  • Haddenham Veni
  • Haddenham Star Cotton – 100% cotton next to skin
  • Juzo Soft

Adjustable wrap – choice depends on shape of leg and patient dexterity

  • Jobst Farrowwrap Lite
  • Medi Juxtalite
  • L&R ReadyWrap

Fatty

Spongy with redundant tissue

Loss of shape with/without skin folds and fat pads

Negative Stemmer’s sign*

Stiff

Stiffer fabric that supports and shapes the tissues and bridges skin folds

Offers higher containment

Stiff circular knit garment (do not use in presence of skin folds), custom flat knit or adjustable wrap

Adjustable wrap can accommodate reduction in girth. May be easier to don and doff.

RAL standard – class 2

Circular knit

  • Jobst Opaque
  • Mediven for men
  • Mediven Active
  • Haddenham Veni
    Haddenham  Star Cotton – 100% cotton next to skin
  • Juzo Soft

Custom flat knit

  • Jobst Elvarex (contains latex) or Elvarex Soft (latex free)
  • Mediven Mondi or Cosy
  • Haddenham Pertex – palliative use only

Adjustable wrap – choice depends on shape of leg and patient dexterity

  • Jobst Farrowwrap Lite or Strong
  • Medi Juxtalite, Juxtafit
  • L&R ReadyWrap

Putty

Early fibrotic changes with putty consistency

Pits with prolonged pressure, rebound >30 seconds

Positive Stemmer’s sign*

Stiff

Stiffer fabric  supports and shapes the tissues and bridges skin folds

Offers higher containment

Stiff circular knit garment (do not use in presence of skin folds), custom flat knit or adjustable wrap.

May benefit from textured insert or garment, eg night garment.

Adjustable wraps are useful over wound dressings and can accommodate reduction in girth. May be easier to don and doff.

RAL standard – class 2 or 3

Circular knit

  • Mediven plus
  • Juzo Dynamic

Custom flat knit

  • Jobst Elvarex (contains latex) or Elvarex Soft
  • Mediven Mondi
  • Haddenham Pertex - palliative use only

Adjustable wrap – choice depends on shape of leg and patient dexterity

  • Jobst Farrowwrap Strong or Classic
  • L&R ReadyWrap

Woody

Fibrotic changes with firm, woody texture

Does not pit even on deep pressure

Positive Stemmer’s sign*

Stiff

Stiffer fabric  supports and shapes the tissues and bridges skin folds

Offers higher containment

Stiff circular knit garment (do not use in presence of skin folds), custom flat knit or adjustable wrap.

May benefit from textured insert or garment, eg night garment.

Adjustable wraps are useful over wound dressings and can accommodate reduction in girth. May be easier to don and doff.

RAL standard – class 2 or 3

Circular knit

  • Mediven plus
  • Juzo Dynamic

Custom flat knit

  • Jobst Elvarex (contains latex)

Adjustable wrap – choice depends on shape of leg and patient dexterity

  • Jobst Farrowwrap Strong or Classic
  • L&R ReadyWrap

Fragile

Thin, fragile skin prone to skin tears, usually watery oedema

 

 

Layered

Layering one compression garment over another increases stiffness and may protect fragile skin from damage during donning and doffing. It is also useful over a wound dressing.

Garments can be layered using leg ulcer kits or using two lighter compression garments, eg Duomed Soft plus a RAL class 1 garment.

 

British standard

  • Medi Duomed Soft

Compression hosiery kit

  • BSN Ulcercare – outer stocking available with zip
  • Urgo Altipress  40
  • L&R leg ulcer hosiery kit
  • These options offer a separate pack of 3 liners

Adjustable wrap – choice depends on shape of leg and patient dexterity

  • Jobst Farrowwrap Lite
  • Medi Juxtalite

* Stemmer’s sign is considered as diagnostic of lymphoedema / chronic oedema.  A positive Stemmer’s sign is the inability to pinch the skin at the base of the second toe due to oedema and fibrosis

Products, available classes and sizes

Category 1: British Standard: Is made from light, thin fabric in a circular knit. It is suitable to manage symptoms of chronic venous insufficiency and prevent venous ulcer and ulcer recurrence in the absence of oedema in a normal shape limb.

Can be used for  palliative patients (Class 1), elderly patients (Class I) and as low compression option for venous oedema

Duomed Soft should be used instead of other British standard hosiery such as Scholl

Duomed Soft Stockings

Product code
Class 1:
14-17 mmHg

 Product code
Class 2:
18-24 mmHg		 Product code
Class 3:
25-35 mmHg
Below knee open toe DT511 DT521 DT531
Below knee closed toe DT512 DT522  
Thigh length open toe DT611 DT621 DT632
Thigh length closed toe DT612 DT622  

Sizes: small, medium, large, X large, XX large

Specify colour and size: add /0 to code for beige or /5 to code for black then add / followed by size (1 – 5) eg DT612/5/3.

Category 2: European/RAL Standard Circular Knit: Is made from stiffer yarn. It is suitable to manage symptoms of chronic venous insufficiency and prevent venous ulcer and ulcer recurrence in the presence of oedema/lymphoedema. It is only suitable for use in a normal shape limb, ie no skin folds or oedema that is greater in one part of the limb such as around the ankle.

Jobst Opaque

Product code
Class 1:
18-21 mmHg

 Product code
Class 2:
23-32 mmHg
Below knee, open toe

For Vision eg: Jobst Opaque class 1 below knee stocking closed toe top band regular size 5 black.

For EMIS eg: Jobst Opaque class 2 black petite tights open toe size 6
Below knee, closed toe
Thigh length, open toe
Thigh length, closed toe
Tights, open toe
Tights, closed toe

Sizes: I to VI

Specify size, knitted top band or soft silicone top band and colour: sand, black or navy.

 

Mediven Plus Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
23-32 mmHg		 Product code
Class 3
33-46 mmHg
Below knee, regular DT101 DT201 DT401
Below knee, petite DT102 DT202 DT402
Below knee, x-wide, regular DT103 DT203 DT421
Below knee, x-wide petite DT104 DT204  
Thigh length, regular DT108 DT200 DT400
Thigh length, petite DT106 DT199 DT399
Thigh length, x-wide DT108X DT200X DT400X
Thigh length, x-wide, petite DT106X DT199X DT399X

Sizes: I to VII

Only available in open toe.

Specify colour and size: add /0 to code for beige or /5 to code for black then add / followed by size (1 – 5) eg DT200/5/3.

 

Mediven for men socks Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
23-32 mmHg
Below knee, closed toe DT324 DT340
Below knee, closed toe DT343 DT341

Sizes: I to VII and I to VII petite

Specify colour and size: add /5 to code for black, /3 for navy or /2 for grey then add / followed by size (1 – 7) eg DT343/2/4.

 

Mediven Active socks Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
23-32 mmHg
Below knee, closed toe DT180 DT280
Below knee, closed toe (only available in black) DT181 DT281

Sizes: I to VII and I to VII petite

Specify colour and size: add /2 for grey, /3 for navy, /5 for black, /6 for brown then add / followed by size (1-7) eg DT280/3/6.

 

Haddenham Veni MTO Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
3-32 mmHg		 Product code
Class 3:
33-46 mmHg
Below knee VE-10 VE-20 VE-30
Below knee with grip top VE-12 VE-22 VE-32
Thigh high VE-11 VE-21 VE-31
Thigh high with grip top VE-13 VE-23 VE-33
Tights VE-17 VE-27 VE-37

Sizes: I to VIII

Specify size, length, open or closed toe, and colour: pearl, black, slate or navy (see order form for extra codes required).

Order form must accompany prescription to pharmacy.

 

Hadenham Star Cotton MTO Product code, class 1 (14-17 mmHg) Product code, class 2 (18-24 mmHg)
Below knee SC-10 SC-20
Below knee with grip top SC-12 SC-22
Thigh high SC-11 SC-21
Thigh high with grip top SC-13 SC-23
Tights SC-17 SC-27

Sizes: I to VIII

Specify size, length, open or closed toe, and colour: beige, black, (see order form for extra codes required).

Order form must accompany prescription to pharmacy.

 

Juzo Soft Product code
Class 1:
14-17 mmHg		 Product code,
Class 2:
18-24 mmHg
Below knee 2001/AD 2002/AD
Below knee with adhesive border 2001/AD 2002/A
Thigh length 2001/AG 2002/AG
Thigh with adhesive border 2001/AG 202/AG
Tights 2001/AT 2002/AG

Sizes: I (XS), II (S), III (M), IV (L), V (XL) and VI (XXL)

Specify size, length, open or closed toe, and colour: almond or black (other colours please specify).

 

Juzo Dynamic Product code
Class 2:
18-24 mmHg		 Product code
Class 3:
33-46 mmHg
Below knee 3512/AD 3513/AD
Below knee with adhesive border 3512/AD 3513/AD
Thigh length 3512/AG 3513/AG
Thigh with adhesive border 3512/AG 3513/AG
Tights 3512/AT 3513/AT

Sizes: I (XS), II (S), III (M), IV (L), V (XL) and VI (XXL)

Specify size, length, open or closed toe, and colour: almond or black (other colours please specify).

Category 3: European/RAL Flat Knit: is made from a stiffer yarn knitted into a flat piece of fabric that is stitched together by a seam. It is suitable for disproportionate limbs with skin folds and patients with severe chronic oedema and lymphoedema. It is available in class 1 (18-21mmHg), class 2 (23-32mmHg) and class 3 (34-46mmHg). Higher classes and more complex garments are available for specialist use, contact Highland Lymphoedema Service for advice High-UHB.highland-lymphoedema@nhs.net.

Jobst Elvarex Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
23-32 mmHg		 Product code
Class 3:
33-46 mmHg
Below knee with slant open toe, beige L1-01-04 L2-02-04 L3-03-04
Thigh length with slant open toe, beige L1-01-06 L2-02-06 L3-03/06

Custom fit: garment is made up of extra codes as required, see below.

  • Closed toe: L-A001
  • Silicone band L-A004
  • Softfit top L-A016
  • Non-standard colour L-A008
  • Slipform: L-A009
  • T-heel: L-A010
  • Zipper: L-A003

Measurement form must accompany prescription unless repeat garment.

Codes for all additions to basic garment must be included.

Contains latex for stiffer garment.

 

Jobst Elvarex Soft Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
23-32 mmHg		 Product code
Class 3:
33-46 mmHg
Below knee with slant open toe, beige L1-10-04 L2-08-04 L3-09-04
Thigh length with slant open toe, beige L1-10-06 L2-08-06 L3-09-06

Custom fit: garment is made up of extra codes as required, see below.

  • Closed toe: L-A001S
  • Silicone band: L-A004S
  • Softfit top: L-A016S
  • Slipform:
  • Non-standard colour: L-A008S
  • T-heel: L-A010S

Measurement form must accompany prescription unless repeat garment.

Codes for all additions to basic garment must be included.

Latex free.

 

Mediven Mondi Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
23-32 mmHg		 Product code
Class 3:
33-46 mmHg
Below knee with slant open toe DTMK1 DTMK2 DTMK3
Thigh length with slant open toe DTMT1 DTMT2 DTMT3

Custom fit: garment is made up of extra codes as required, see below.

  • Silicone topband: DTTB
  • Closed toe: DTTOE
  • Zip: DTZIP

Measurement form must accompany prescription unless repeat garment.

Codes for all additions to basic garment must be included.

Latex free.

 

Mediven Cosy Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
23-32 mmHg		 Product code
Class 3:
33-46 mmHg
Below knee with slant open toe DTCK1 DTCK2 DTCK3
Thigh length with slant open toe DTCT1 DTCT2 DTCT3

Custom fit: garment is made up of extra codes as required, see below.

  • Silicone topband: DTTB
  • Closed toe: DTTOE
  • Zip: DTZIP

Measurement form must accompany prescription unless repeat garment.

Codes for all additions to basic garment must be included.

Latex free.

 

Haddenham Pertex Product code
Class 1:
18-21 mmHg		 Product code
Class 2:
23-32 mmHg		 Product code
Class 3:
33-46 mmHg
Below knee PX-21 PX-22 PX-23
Thigh length PX-31 PX-32 PX-33

Palliative use only

Custom fit: garment is made up of extra codes as required, see below.

  • Grip top CM-90
  • Zip CM-92
  • Velcro strap CM-94

Measurement form must accompany prescription unless repeat garment

Latex free.

Category 4: inelastic adjustable compression garments: These garments provide an effective alternative for patients who are able to self manage their care, those with rebound oedema when changed to stockings and for those with fragile skin or dexterity problems.

Dressings can be applied below these garments offering an effective alternative to bandaging (Damstra & Partsch, 2015). They are useful in ensuring consistency of sub-garment pressure in settings where several carers may be involved in the application of compression.

Despite their relatively high initial cost there is evidence that they can be a cost effective alternative to bandaging when nursing time and the cost of bandages is taken into consideration (Williams, 2016). They are supplied with a liner stocking.

Farrowwrap, and Juxta Fit are all available as a custom option for those who do not fit into standard sizes.

Jobst Farrowwrap

Light:
20-30 mmHg

Strong:
30-40 mmHg

Classic:
30-40mmHg
Footpiece     This is a stiff fabric suitable for resistant oedema likely to rebound.
Legpiece    
Thigh length    
Sizes: X small, small, medium, large and X large

If ordering foot and leg piece together, a stretchy liner stocking is provided.  Available in beige only.

 

Medi Juxta Juxta Lite Juxta Cures
Footpiece - only available in Juxta Fit Compression liner sock provided eliminating need for separate footpiece.

This wrap offers the best fit in presence of lipodermatosclerosis (champagne shaped calf).

Sized on length only.
Legpiece
Thighpiece - only available in Juxta Fit
Sizes: X small, small, medium, large, X large and XX large

Only available in beige.  Compression anklet provided with Juxta Cures eliminating need for separate footpiece.

 

L&R ReadyWrap

  • Description:Foot (left or right), Calf, Knee, Thigh
  • Sizes: small, medium, large, X large and XX large
  • Colours: Available in beige or black.  
  • Available to two lengths.

Category 5: Leg Ulcer Hosiery Kits: Although compression bandages are the recommended first line treatment for venous leg ulcers, hosiery kits provide a useful alternative in patients who prefer to self manage their care. They are recommended for the management of venous ulcers after oedema reduction and for helping to prevent the recurrence of such ulcers for people who may otherwise have difficulty in donning garments as they comprise two components which together provide a nominal compression of 40mmHg at the ankle with a decreasing gradient from distal to proximal. Separate liner packs are available.

Urgo Altipress 40® Sizes: S, M, L, XL, XXL Available in below knee short, regular and long options. Up to 50cm calf
Jobst Ulcercare Sizes: S, M, L, XL, 2XL, 3XL, 4XL

Available in below knee, one length only.  Available with right or left zipper. Up to 60cm calf.
Activa  Sizes: S, M, L, XL, XXL Available in below knee, one length only. Up to 50cm calf.

Appendix 1 - Examples of donning aids available on Scottish Drug Tariff (June 2020)

Easy Slide for open toe stocking

Product code    PIP code   Size          Shoe Size

EO 1102            266-9935    Small         2-4
EO 1202            266-9943    Medium      5-7½
EO 1302            266-9950    Large         8-11
EO 1352            266-9968    XL             >11

Website for video showing application: http://www.daylong.co.uk/brand/brand/arion/easy-slide-hosiery-application-aid.html

Magnide Hosiery Applicator for closed or open toe stockings

Size
Medium
Large
Extra large

Website information: http://www.daylong.co.uk/other/products/application-aids/arion-magnide-hosiery-application-aid.html

Medi 2in1 Donning and doffing aid

Product code: DT904

Website for video: https://www.mediuk.co.uk/drug-tariff/medi-2in1/

Sigvaris Rolly

Product code 64655

Medi Big Butler

Compression hosiery applicator

Product code     DT9008                                  
One size

EZY-As

Compression hosiery applicator

Product code       PIP code    Size

SAS-08017            354-5886    Small
SAM-06264           354-5878    Medium
SAL-06264            354-5880    Large
Ezy-As Handle for greater length
UHA-07246           354-5852

Website: http://www.ezyasabc.co.uk/

Appendix 2 - Lower Limb Compression Therapy Selection Guide

For use following full patient assessment.

References

BLS, (2021), Assessing vascular status in the presence of chronic oedema prior to the application of compression hosiery, British Lymphology Society 

NWCSP, (2020), Lower limb: Recommendations for clinical care, National Wound Care Strategy Programme

Neill K, Turnbull K, (2012) Use of specialist knowledge and experience to manage patients with mixed aetiology ulcers, Journal of Wound Care 21 (4), pp168-174

Best Practice Statement: Compression Hosiery: A Patient-Centric Approach (3rd Edition), (2021) Wounds UK

Editorial Information

Last reviewed: 30/06/2022

Author(s): Wound and Tissue Viability.

Version: 1

Reviewer name(s): Louise Shakespeare, Advanced Nurse Lymphoedema.

Document Id: F001