Venous leg ulcers and diabetic foot ulcers are often discussed as separate problems, yet many people with diabetes have chronic venous insufficiency, peripheral artery disease (PAD), or both. When a lower-leg wound has venous, arterial, and neuropathic contributors, the central treatment question becomes whether compression, the cornerstone of venous ulcer care, is safe and effective. Recent evidence offers a more nuanced answer than the old rule that diabetes means no compression.
Compression Is the Evidence-Based Standard for Venous Ulcers
A Cochrane systematic review by Shi and colleagues (2021) pooled 14 randomized trials including 1,391 participants and compared compression bandages or stockings with no compression for venous leg ulcers. Compression was associated with faster healing (pooled hazard ratio 2.17, 95% CI 1.52 to 3.10) and a higher likelihood of complete healing within 12 months (relative risk 1.77, 95% CI 1.41 to 2.21). The review could not determine with confidence whether compression increases adverse events, and most trials ran for roughly 12 weeks, so longer-term safety data are limited.
Importantly, the trials in this review were conducted largely in people with venous disease and adequate arterial supply. They do not directly answer the question for patients whose ulcers are complicated by diabetes or arterial insufficiency.
What Is Known About Compression in People With Diabetes
Mosti, Cavezzi, Bastiani, and Partsch (2020) examined outpatients with recalcitrant venous or mixed arterial-venous leg ulcers, comparing 73 people with non-insulin-dependent diabetes with 107 people without diabetes. Of the 180 patients, 155 were analyzed after loss to follow-up. All received inelastic compression bandages (about 60 mm Hg for venous ulcers and about 40 mm Hg for mixed ulcers) together with ultrasound-guided foam sclerotherapy of superficial venous reflux.
Median healing times were similar in absolute terms, at 25 weeks in non-diabetic versus 28 weeks in diabetic patients with venous ulcers, and 27 versus 29 weeks in mixed ulcers. In a multivariate model, diabetes was associated with significantly slower healing in pure venous ulcers (hazard ratio 0.460, 95% CI 0.284 to 0.746) but not in mixed ulcers. The authors reported no compression-related safety signal, including in patients with moderate PAD (ankle-brachial pressure index 0.5 to 0.8), and concluded that compression is not contraindicated in diabetes. They considered critical limb ischemia, with an ankle pressure below 60 mm Hg, to be the true contraindication, and suggested that a toe pressure above 30 mm Hg may allow reduced, modified compression not exceeding 40 mm Hg.
This was a retrospective, single-cohort analysis without a sample-size calculation, and its statistical power was low. It supports cautious optimism rather than a definitive recommendation, and the authors themselves call for prospective randomized trials.
Why Perfusion Assessment Comes First
In diabetes, the ankle-brachial index can be falsely normal or elevated because of medial arterial calcification, which makes arterial status easy to underestimate. The intersocietal IWGDF, ESVS, and SVS guideline on peripheral artery disease in people with diabetes and a foot ulcer (Fitridge et al., 2023) emphasizes that PAD should be assessed in every person with a diabetic foot ulcer, using measures such as toe pressure and toe-brachial index alongside clinical examination and Doppler waveforms, and that urgent revascularization assessment is warranted when limb-threatening ischemia is present. Because compression raises tissue pressure around vessels that may already be compromised, reliable perfusion data are a prerequisite for any compression decision in a patient with diabetes.
Neuropathy adds a further consideration. Loss of protective sensation means a patient may not feel pain from an overly tight bandage, so skin should be inspected carefully and compression pressures verified rather than guided by symptoms.
Putting the Evidence Together
The available evidence suggests a practical framework. First, establish the ulcer’s cause by combining clinical examination with objective vascular testing. Second, where venous disease is present and arterial supply is adequate, compression is supported by high-quality evidence for healing. Third, where PAD is moderate, reduced or modified compression has been used without a reported safety signal in small observational data. Fourth, where critical limb ischemia is present, compression is generally avoided and vascular assessment takes priority.
Conclusion
Diabetes does not automatically exclude compression therapy for venous or mixed leg ulcers, but it raises the stakes of getting the vascular assessment right. Compression has robust randomized evidence in venous ulcers; evidence in diabetic and mixed-disease populations is limited to observational data, which indicates slower healing in diabetic venous ulcers but no clear excess of harm when arterial disease is not severe. Perfusion testing with toe pressures, attention to sensory loss, and individualized compression levels are the main safeguards.
References
- Shi C, Dumville JC, Cullum N, et al. Compression bandages or stockings versus no compression for treating venous leg ulcers. Cochrane Database of Systematic Reviews. 2021.
- Mosti G, Cavezzi A, Bastiani L, Partsch H. Compression therapy is not contraindicated in diabetic patients with venous or mixed leg ulcer. Journal of Clinical Medicine. 2020;9(11):3709.
- Fitridge R, Chuter V, Mills J, et al. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes/Metabolism Research and Reviews. 2023.
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