Compression Therapy Cuts Cellulitis Risk in Chronic Leg Edema

Troy Brown, RN

August 17, 2020

For patients with chronic leg edema and recurrent cellulitis, risk for future cellulitis is reduced by 77% by wearing compression stockings or wraps, researchers report. The effect was so striking that the randomized controlled trial was stopped early and all patients in the study were given the therapy.

"In a climate of increasing antibiotic resistance, we are delighted to have discovered a nondrug management strategy that has such a dramatic impact on the risk of cellulitis," senior author Bernie Bissett, PhD, from the Discipline of Physiotherapy, Faculty of Health, the University of Canberra, Australia, told Medscape Medical News.

"We hope this leads to a shift in preventative medical strategy for patients with chronic edema and cellulitis around the world," she said.

Lead author Elizabeth Webb, MPH, from the Physiotherapy Department at Calvary Public Hospital Bruce, in Bruce, Australia, and colleagues report their findings in an article published online August 12 in The New England Journal of Medicine.

Bisset explained that Webb is a "leading lymphedema physiotherapist" and a PhD candidate at the University of Canberra. She added that this is the first study to show that "compression therapy dramatically reduces the risk of cellulitis for patients with chronic edema."

Cellulitis is a common bacterial infection that affects the skin and subcutaneous tissue. It occurs primarily in the legs and frequently recurs. Penicillin is often given preventively; some research suggests effectiveness wanes after the antibiotic is stopped.

For the current trial, Webb and colleagues enrolled 84 adults with chronic edema of the leg and recurrent cellulitis. They randomly assigned patients in a 1:1 ratio to receive leg compression therapy plus education about preventing cellulitis (compression group; n = 41) or education only (control group; n = 43).

Compression therapy consisted of wearing knee-high stockings that applied maximum compression at the ankles. The compression gradually decreased up the legs. In addition, 26 patients were treated with "therapist-applied compression bandaging" for 3 to 5 days before receiving the stockings.

Participants underwent follow-up assessments every 6 months for a maximum of 3 years or until 45 episodes of cellulitis, the primary outcome, occurred. Those in the control group crossed over to the compression group once they experienced cellulitis.

The trial was stopped early for reasons of efficacy. "The statistical analysis plan prespecified that after 23 episodes of cellulitis had occurred, an independent data monitoring committee would review the results of the interim analysis and recommend whether the trial should stop early," the authors write.

At the time of the monitoring committee's review, six patients (15%) who wore compression stockings and 17 (40%) in the control group had experienced a cellulitis episode (hazard ratio, 0.23; P = .002; relative risk [post hoc analysis], 0.37; P = .02). On the basis of those findings, the researchers stopped the study, and patients in the control group were started on compression therapy.

"Clinicians should definitely consider referring their patients to a skilled lymphedema therapist who can individually prescribe and fit compression garments," Bissett said. "In our study, these were well tolerated and reduced the risk of another episode of cellulitis by a huge 77%," she added.

Secondary outcomes included hospitalization related to cellulitis and quality-of-life assessments.

Three patients (7%) in the compression group and six (14%) in the control group were admitted to the hospital for cellulitis (hazard ratio, 0.38). There were no differences in quality-of-life outcomes between the treatment groups.

The authors say compression therapy has the potential to decrease cellulitis risk by reducing edema, boosting immune response and skin integrity, and protecting the skin.

"Patients with a history of leg swelling (chronic edema) and previous episodes of cellulitis are ideal candidates for this compression therapy," Bissett said.

"Given the lack of side effects of the therapy in our study and the potential to reduce other skin problems in these patients, compression therapy is an ideal prophylactic strategy," she said.

The authors note several study limitations, including a lack of blinding. In addition, patients in the study had to have access to lymphedema specialists, who might be unavailable to patients outside the study. This could have influenced adherence and limits generalizability. Difficulty putting on and taking off compression garments often leads patients to be less adherent to compression therapy, but 88% of patients in this study wore them at least 4 days per week.

Bissett said compression therapy would be useful for primary care physicians to consider for patients with chronic edema.

"Primary care physicians are highly likely to encounter patients with chronic edema in their day-to-day practice. We can now confidently say that referral to lymphedema therapists for compression therapy should be a first line of defense against future episodes of cellulitis in this vulnerable patient group," she explained.

The authors have disclosed no relevant financial relationships.

New Engl J Med. Published online August 12, 2020. Abstract

Troy Brown is an award-winning Medscape contributor with a special interest in infectious diseases, women's health, and pediatrics.

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