For patients with chronic venous insufficiency (C.V.I), discomfort can make it difficult to stay compliant with treatment. And when compression isn’t worn as intended, even proven treatment can fall short
Up to 15–30% of chronic venous insufficiency (C.V.I.) patients remain unhealed after six months of standard compression therapy. Research shows that discomfort—particularly pruritus—is a direct cause of non-compliance in one in five patients. Addressing patient comfort is not peripheral to C.V.I. management. It is central to it.
Compression therapy works. The clinical evidence base is substantial, the mechanism is well-understood, and for nurses and wound care specialists managing chronic venous insufficiency, it remains the gold standard treatment for venous leg ulcers (VLUs). So why are so many patients still not healing?
One factor may be what happens after compression is applied: whether patients can tolerate wearing it as intended.
Non-compliance in compression therapy is one of the most persistent challenges in CVI management. Patients remove wraps early. They push bandages down. They tolerate compression for a day or two before discomfort becomes the deciding factor. And when that happens, even the most clinically appropriate system cannot deliver the sustained therapeutic pressure patients need to heal.
How significant is the non-response rate in compression therapy?
Research from both clinical trials and real-world vascular settings shows that a significant portion of CVI patients remain unhealed after months of standard compression treatment. Findings from the APRICOT trial published in the British Journal of Community Nursing (Jonker et al., 2020), and the PEACH trial, published in the Journal of Vascular Nursing (Todhunter et al., 2025), point to a persistent gap between treatment and healing.
For nurses managing these patients across community and hospital settings, it is a familiar and frustrating reality. Compression is prescribed, applied correctly and reviewed. Yet some patients fail to progress. Wound breakdown recurs. The cycle continues.
What drives that non-response rate? There is no single cause. Comorbidities, wound chronicity, arterial involvement and patient mobility all play a role. But one contributing factor is documented, measurable and, critically, addressable: the physical experience of wearing compression.
What skin changes and symptoms do CVI patients experience under compression?
CVI is not simply a vascular condition. For many patients, it also comes with significant skin changes. According to Kilinc et al. (2021), 82.7% of CVI patients experience at least one skin change, including venous eczema, lipodermatosclerosis , scaling, blistering, and maceration. These symptoms can make sustained compression wear difficult for patients to endure.
The PEACH trial also found aching legs, swelling and throbbing to be prevalent among patients with leg ulcers. These are not minor inconveniences. For a patient managing a chronic condition over weeks and months, they represent a persistent, daily burden that shapes every decision about whether the bandage stays on.
And then there is pruritus.
Pruritus, or itching, is documented as the most common and most troublesome symptom associated with wearing compression bandaging. In the APRICOT trial, itchiness was reported most frequently and rated as the most severe symptom by participants. According to Reich-Schupke et al. (2009) and Stansal et al. (2013), pruritus develops in as many as one in three patients wearing compression bandaging.
Why is pruritus a direct cause of non-compliance?
For patients, non-compliance can happen in ordinary moments. A patient who itches at 3 a.m. does not call the clinic. They push the bandage down. They remove it. They scratch. And in doing so, they interrupt the sustained therapeutic compression that wound healing depends on. One night of disrupted wear can extend a treatment cycle. Repeated episodes can stall healing entirely.
This may not be a patient motivation problem. It may be a comfort problem. The behavior is documented and can be linked to the physical experience of wearing compression on already-compromised skin.
The APRICOT trial provides a striking illustration of this connection. One patient in the trial could only tolerate the comparator bandage (Coban2) for two days before requiring a change due to discomfort. The same patient wore the calamine-infused compression system for four consecutive days. While this represents a single patient experience, it illustrates how the physical experience of wearing compression can influence sustained wear.
Why comfort is a clinical variable, not a patient preference
When comfort is viewed primarily as a patient preference, it becomes secondary to clinical performance metrics like healing rates and interface pressure. The patient’s experience of wearing the system becomes something to manage rather than a factor in treatment selection.
But when comfort is recognized as a clinical variable that can influence whether patients wear their compression for the intended duration —the equation changes.
A compression system that patients tolerate for two days delivers two days of therapeutic pressure. One they tolerate for seven delivers seven. Comfort, then, can play an important role in closing the gap between prescribed treatment and sustained wear.
The CIVIQ-20 framework, used to measure patient-reported quality of life (QoL) in chronic venous disease, provides another way to understand the impact of these symptoms. Mobility, daily function and symptom burden are measurable clinical outcomes. When pruritus, aching or movement restriction becomes severe enough that patients alter their behavior by pushing bandages down, removing wraps early or avoiding activity, the impact extends beyond comfort alone.
QoL is not a soft metric. It reflects how the treatment experience affects patients beyond the wound itself.
How does addressing comfort in compression therapy lead to better clinical outcomes?
When patients can tolerate compression across the intended wear period, it helps deliver consistent therapeutic pressure. That pressure reduces venous hypertension, supports edema reduction and creates a wound environment in which healing can progress. Interrupted compression breaks that chain.
Considering comfort at the point of compression selection can help support sustained wear and ultimately, the conditions needed for healing.
Bridging the gap between symptom awareness and better compression outcomes
Nurses and wound care specialists already recognize non-compliance as a challenge. Most can describe the patient who pushed the bandage down, who removed the wrap overnight, who arrived at the next appointment with the compression barely in place. That behavior pattern is familiar.
What this evidence asks clinicians to consider is what may be contributing to that behavior, and whether the experience of wearing compression is part of it.
Understanding the comfort-compliance link can help clinicians select systems that support sustained wear. At each patient encounter, the question becomes: Does the compression being prescribed make it possible for this patient to stay compliant?
That is a question worth asking before the next bandage goes on.
Frequently asked questions
Why does patient compliance matter so much in compression therapy for CVI?
Compression therapy for CVI works through sustained therapeutic pressure that reduces venous hypertension and supports wound healing. Interrupted wear—even for short periods—breaks that therapeutic effect. When patients remove or adjust compression due to discomfort, the clinical benefit is reduced or lost. Compliance is not a secondary concern; it determines whether the therapy delivers its intended outcome.
How common is pruritus in patients wearing compression bandaging?
Pruritus is the most commonly reported and most troublesome symptom associated with wearing compression bandaging. Research cited in the APRICOT trial (Jonker et al., 2020) indicates that pruritus develops in as many as one in three patients. Of those, pruritus is a direct cause of non-compliance in one in five patients (Ayala et al., 2019; Stansal et al., 2013).
What skin changes affect CVI patients and how do they contribute to non-compliance?
According to Kilinc et al. (2021), 82.7% of CVI patients experience at least one skin change finding. These include venous eczema, scaling, maceration and inflammation. These changes create a symptomatic environment—characterized by itching, discomfort and heat—that makes wearing compression difficult. When the compression itself exacerbates those symptoms, patients are more likely to alter or remove their bandaging.
What symptoms most commonly undermine compression therapy adherence in CVI patients?
The PEACH trial (Todhunter et al., 2025) recorded symptom burden at baseline using the VEINES Sym questionnaire. Patients reported aching legs, leg swelling and throbbing as the most prevalent symptoms. The APRICOT trial identified pruritus as the most common and most severe symptom specifically associated with wearing compression bandaging.
What is the CIVIQ-20 and why is it relevant to compression therapy decisions?
The Chronic Venous Disease Quality of Life Questionnaire (CIVIQ-20) is a validated patient-reported outcome measure assessing quality of life across domains including pain, physical function, social function and psychological wellbeing. It is clinically relevant to compression therapy because it captures the real-world impact of symptom burden on daily life—including mobility, activities and emotional wellbeing. When compression causes or worsens symptoms, CIVIQ-20 scores reflect that impact, making patient-reported QoL a meaningful metric alongside healing rates.
What does the 15–30% non-response rate in compression therapy mean for clinical practice?
This figure, cited in both the APRICOT (Jonker et al., 2020) and PEACH (Todhunter et al., 2025) trials, indicates that a significant proportion of CVI patients remain unhealed after six months of standard compression treatment. While multiple factors contribute—comorbidities, wound chronicity and arterial involvement among them—non-compliance driven by discomfort is a documented and modifiable contributor. Recognizing comfort as a clinical variable rather than a patient preference is one practical response to this challenge.