🟢 Strong Evidence
A large randomised controlled trial published in PLOS Medicine found that two-layer compression bandages achieve venous leg ulcer healing rates comparable to the current standard four-layer compression therapy. The pragmatic trial, conducted across 33 United Kingdom sites between February 2021 and August 2024, enrolled 637 adults with venous leg ulcers and randomly assigned them to compression wraps, two-layer bandages, or evidence-based compression (four-layer bandages or two-layer hosiery).
Key takeaways
- Two-layer compression bandages achieved non-inferior healing rates compared to four-layer compression and two-layer hosiery in venous leg ulcer treatment
- Compression wraps showed significantly slower healing than evidence-based compression strategies
- Findings support cost-effective alternatives to complex four-layer systems without compromising patient outcomes
Study at a Glance
| Source | PLOS Medicine |
| Study type | Pragmatic, three-arm randomised controlled trial |
| Sample size | N = 637 (213 compression wraps, 211 two-layer bandage, 213 evidence-based compression) |
| Population | Adults with venous leg ulcers appropriate for compression therapy |
| Country | United Kingdom |
Healing outcomes by compression strategy
Time to ulcer healing across three treatment arms, adjusted for baseline factors
Source: VenUS 6 Trial, PLOS Medicine, 2025 | Georgian Medical Journal News
Simplifying compression without losing effectiveness
The trial, led by researchers from multiple UK institutions including the University of Manchester and University of Leeds, compared three approaches to venous leg ulcer compression therapy. According to the VenUS 6 trial published in PLOS Medicine, two-layer compression bandages demonstrated non-inferior healing times compared to evidence-based compression (EBC)—defined as four-layer bandages or two-layer compression hosiery—which represents current best practice guidance.
The non-inferiority finding challenges the assumption that more complex compression systems necessarily deliver superior outcomes. Two-layer bandages require fewer materials and less application time than four-layer systems, potentially reducing healthcare resource demands while maintaining clinical efficacy. This suggests that clinical updates in compression therapy may soon reflect this simplified approach.
Compression wraps fall short of standard care
By contrast, compression wraps—consumer-accessible elastic garments without the layered structure of clinical bandages—showed significantly slower healing compared to both two-layer bandages and evidence-based compression. The hazard ratio for healing with compression wraps versus EBC favoured EBC, indicating clinically meaningful delays in ulcer closure with wrap-only therapy. This distinction is critical for quality and safety standards in wound management.
The trial’s pragmatic design, conducted in real-world UK NHS settings rather than controlled research environments, strengthens the generalisability of findings to routine clinical practice. Participants and clinical staff were not blinded to treatment allocation—a methodological choice that reflects the practical reality of compression therapy delivery, where clinicians and patients cannot be masked to whether they are applying bandages or wraps.
Cost and accessibility implications for wound care services
The non-inferiority of two-layer bandages over four-layer compression has direct implications for resource-constrained healthcare systems. Two-layer systems require fewer materials per application, demand less training complexity, and generate lower waste streams than four-layer alternatives. For patient care pathways across the UK’s National Health Service and similar publicly funded systems, this finding suggests that effective ulcer healing can be achieved without escalating to four-layer complexity in all cases.
The VenUS 6 trial enrolled 637 participants across urban and rural UK sites between February 2021 and August 2024, with blind outcome assessment by independent evaluators to reduce detection bias. Healing was documented photographically and assessed by researchers unaware of treatment allocation, strengthening confidence in the primary outcome measurement.
Two-layer compression bandages achieved non-inferior healing rates compared to four-layer compression bandages and two-layer hosiery, while compression wraps showed significantly slower healing than evidence-based compression strategies.
— VenUS 6 Trial Investigators, PLOS Medicine, 2025
What this means
Frequently asked questions
Why is the two-layer vs. four-layer comparison important?
Four-layer compression bandages are the current recommended standard for venous leg ulcer treatment in most clinical guidelines. If two-layer systems prove non-inferior, healthcare systems can simplify training, reduce material waste, and lower costs without sacrificing healing rates. The VenUS 6 trial provides rigorous evidence to support this potential shift in practice.
What are compression wraps, and why did they perform worse?
Compression wraps are elastic garments designed for consumer use and general compression support. They lack the consistent pressure profile and layered structure of clinical bandages, resulting in significantly slower ulcer healing. According to the trial findings, they should not be relied upon for therapeutic venous ulcer treatment.
How does this trial change clinical practice guidelines?
The VenUS 6 evidence supports revision of compression therapy guidance to elevate two-layer bandages to non-inferior status with four-layer systems. This allows clinicians and patients greater flexibility in choosing effective, practical approaches. However, compression wraps remain unsuitable for clinical-grade ulcer management based on this evidence.
The VenUS 6 trial represents one of the largest pragmatic comparisons of compression strategies for venous leg ulcers conducted in a modern healthcare system. As healthcare providers worldwide seek to optimise wound care efficiency without compromising outcomes, these findings offer an evidence-based pathway to simplify compression therapy protocols. Future implementation research will be essential to track real-world adoption rates and sustained outcomes as NHS services and international systems integrate two-layer compression as a first-line standard.
Source: VenUS 6: Compression therapies for venous leg ulcers—an open, multicentre, randomised clinical trial, PLOS Medicine, 2025
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