🟢 Strong Evidence
A large randomised controlled trial published in PLOS Medicine found that two-layer compression bandages achieved equivalent healing rates to four-layer compression bandages and two-layer hosiery for venous leg ulcers. The trial, known as VenUS 6, enrolled 637 participants across 33 UK primary care, community, and hospital sites between February 2021 and August 2024, making it one of the largest pragmatic effectiveness studies in compression therapy for venous wounds.
Key takeaways
- Two-layer compression bandages did not fall below the non-inferiority threshold compared to evidence-based compression (four-layer bandages and two-layer hosiery), meeting the trial’s primary outcome
- Compression wraps—a newer, easier-to-apply option—showed no superiority over either two-layer or four-layer compression in healing time
- These findings support clinical flexibility in compression therapy selection and may reduce treatment costs in primary and community care settings
Study at a Glance
| Source | PLOS Medicine |
| Study type | Open, pragmatic, multicentre randomised controlled trial (non-inferiority and superiority design) |
| Sample size | N = 637 participants |
| Population | Adults with venous leg ulcers appropriate for compression therapy |
| Country | United Kingdom (33 sites across primary, community, and hospital care) |
Trial arm allocation and primary comparison design
VenUS 6 randomisation strategy (three treatment arms, 1:1:1 allocation), UK sites, 2021–2024
Source: VenUS 6 Trial, PLOS Medicine, 2024 | Georgian Medical Journal News
Two-layer bandages achieve non-inferiority to established four-layer compression
The trial’s primary analysis focused on comparing two-layer bandages (the intervention under investigation) with evidence-based compression—a composite category including both four-layer bandages and two-layer compression hosiery, the current recommended standard. According to the VenUS 6 investigators led by Catherine Arundel at the University of Manchester and colleagues across the UK’s National Institute for Health and Care Research (NIHR), two-layer compression bandages met the pre-specified non-inferiority margin, demonstrating that healing times did not fall clinically below the four-layer standard.
This finding is significant because two-layer bandages are simpler to apply, require less training, and impose lower material costs than four-layer systems. The trial’s pragmatic design—conducted in real-world primary and community care settings rather than specialist centres—strengthens the relevance of the findings to routine NHS practice, where compression therapy is most often initiated.
Compression wraps show no advantage over traditional bandaging
The trial also evaluated compression wraps, a newer class of ready-made, self-adherent compression garments marketed as easier to apply and more patient-friendly than traditional bandages. In superiority analyses, the VenUS 6 team found no statistically significant difference in healing times between compression wraps and either two-layer bandages or four-layer compression bandages. This suggests that despite their ease of use, wraps do not offer faster ulcer healing—a key therapeutic outcome in venous wound management.
The absence of superiority for compression wraps does not preclude their clinical use but indicates that if they are chosen, it should be on grounds of patient preference, adherence, or practical fit rather than expected improvement in healing speed. This supports a more individualised approach to compression selection, aligned with shared decision-making principles in modern wound care.
Real-world evidence supports flexibility in compression selection
The VenUS 6 trial enrolled 637 adults with venous leg ulcers across 33 UK sites (primary, community, and hospital care) between 3 February 2021 and 31 August 2024. Participants and clinical staff were not blinded to treatment allocation—a limitation acknowledged by the researchers but reflective of how compression therapy is delivered in practice. Healing was objectively assessed through blind review of standardised photographs, reducing observer bias in the primary outcome.
The trial used Cox proportional hazards regression to analyse time to healing, adjusting for baseline ulcer characteristics, participant age, mobility status, and recruitment site. The findings support clinical and economic flexibility: two-layer bandages, which require fewer materials and shorter application times than four-layer systems, can be confidently recommended as a first-line compression option in primary and community care without compromise to healing outcomes.
Two-layer compression bandages met the pre-specified non-inferiority margin compared to evidence-based compression (four-layer bandages and two-layer hosiery), and compression wraps showed no superiority over either traditional compression method in healing time.
— VenUS 6 Trial Investigators, NIHR, University of Manchester (PLOS Medicine, 2024)
What this means
Frequently asked questions
What is the difference between two-layer and four-layer compression bandages?
Four-layer compression bandages (the UK standard, introduced by the Royal College of Nursing in the 1990s) combine multiple components: padding, compression, elastication, and outer protection, typically achieving 40 mmHg compression at the ankle. Two-layer bandages use fewer components but are easier to apply, require less training, and cost less. The VenUS 6 trial found that both achieve equivalent healing rates for venous leg ulcers.
Are compression wraps a replacement for traditional bandages?
No. While compression wraps are convenient and may improve patient adherence due to easier application and less frequent dressing changes, the VenUS 6 trial found no difference in healing speed compared to two-layer or four-layer bandages. They are a valid option but not superior clinically; choice should be based on patient preference, fit, and practical factors rather than expected faster healing.
Why is this trial important for primary care and the NHS?
Venous leg ulcers are common and costly to treat over months. Two-layer bandages are simpler and cheaper to apply than four-layer systems, meaning they can be used confidently in primary and community care without specialist training. This pragmatic UK trial proves non-inferiority in real-world settings, supporting equitable access to effective compression therapy and potentially reducing NHS treatment costs while maintaining healing outcomes. See Clinical Updates for more on evidence-based wound care.
The VenUS 6 trial advances the evidence base for compression therapy in venous leg ulcer management by directly comparing three contemporary approaches in a large, pragmatic UK sample. These findings support clinical flexibility, patient-centred decision-making, and potential cost efficiency in primary and community care—key priorities for the NHS as it optimises care pathways for chronic wounds. Further research exploring long-term outcomes, cost-effectiveness, and patient-reported outcomes (such as quality of life and satisfaction) would strengthen evidence for individualised compression selection across diverse patient populations.
Source: VenUS 6: Compression therapies for venous leg ulcers—an open, multicentre, randomised clinical trial, PLOS Medicine, 2024
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