PhD, MA, RGN, DN
Professor of Nursing and Co-director of the Centre for Research and Implementation of Clinical Practice
Thames Valley University, London, UK.
Four-layer bandaging is a high-compression bandaging system (sub-bandage pressure 35-40mmHg at the ankle) that incorporates elastic layers to achieve a sustained level of compression over time. Since the development of the four-layer system over 15 years ago, compression therapy has become widely accepted as the cornerstone of venous leg ulcer treatment.
Clinical indications for use
The four-layer bandage system is primarily used in the treatment of venous ulceration and achieves healing in patients with both deep, superficial and combined venous incompetence , , . Four-layer bandaging can also be used to prevent recurrence in patients who are unable to wear elastic hosiery. Vulnerable patients with conditions such as Alzheimer's disease have been managed successfully in this way with the bandage changed every 1-2 weeks.
There is increasing clinical experience of using four-layer bandaging in patients with venous lymphatic disorders. The short-stretch, inelastic effect noted in four-layer bandaging has made this a useful treatment option, although modifications to the application are required. Further indications for the use of four-layer bandaging include conditions where edema hinders wound healing, such as pretibial lacerations (Box 1).
Clinical indications for use of four-layer bandaging
Treatment of venous ulceration
Prevention of ulcer recurrence if hosiery is not tolerated
Symptomatic relief of superficial thrombophlebitis
Traumatic wounds with local oedema, for example pretibial lacerations
Ulceration of mixed aetiology with an oedematous component
During the early stages of the development of the four-layer bandage, alterations to the system were made so that reduced levels of compression could be applied to patients with mixed aetiology ulceration (those with both venous hypertension and mild to moderate arterial disease) . Further research is required to examine the most effective methods of treating these patients.
However, reduced or light compression using three-layer bandaging (with sub-bandage pressure 17-25mmHg), omitting one elastic layer, has been used with encouraging results in a number of studies . Current recommendations suggest that a Doppler ankle brachial pressure index (ABPI) is a useful guide to aid decisions concerning compression and to exclude patients with significant arterial disease (Box 2). According to the RCN Institute's clinical guidelines  and the International Leg Ulcer Advisory Board recommendations , an APBI greater than 0.8 usually indicates venous ulcers, with arterial involvement suggested by an APBI of less than 0.8. Mixed venous/arterial ulcers may have an APBI of 0.5-0.8. Although compression is not usually recommended with an APBI of lower than 0.8, it has been used successfully in patients with an APBI as low as 0.5 .
No decisions regarding the application of compression should be made without a full patient assessment . Ankle brachial pressure readings, while highly reproducible, require accurate technique and careful interpretation of the findings, including an understanding of the significance of altered wave forms and the impact of vascular calcification on systolic pressures. Assessment must therefore take account of the presenting signs and symptoms, such as intermittent claudication, rest pain and signs of poor distal perfusion. The degree of severity and distribution of arterial disease requires more complex evaluation using Duplex ultrasonography and angiography.
Recommendations for use of four-layer bandaging
Based on current RCN and SIGN guidelines ,  and the International Leg Ulcer Advisory Board recommendations 
High compression-sub-bandage pressure 35-40mmHg
ABPI ≥0.8: four-layer bandaging (4LB - orthopedic wool, crepe, elastic layer, cohesive layer)
Reduced compression-sub-bandagepressure 17-25mmHg
ABPI 0.7: three-layer bandaging (orthopedic wool, crepe, cohesive layer)
ABP1 0.6: three-layer bandaging (orthopedic wool, crepe, long-stretch elastic layer)
ABPI <0.5: avoid compression except with medical supervision
There are few absolute contraindications to the use of high compression , although failure to identify arterial disease will result in the unsafe application of this therapy. All patients must be individually assessed for risk.
Patients with decompensated heart failure should not receive high-compression therapy. In this instance high compression will redistribute blood towards the center of the body, thereby increasing there-load of the heart and possibly causing further overload and death .
In addition, patients with severe obliterate arteriosclerosis (for example with an ABPI <0.5) should not receive compression therapy. For patients with mixed aetiology ulceration who undergo reconstructive surgery there is growing anecdotal evidence that, providing there is adequate perfusion following surgery, venous hypertension can be managed safely with compression. However, careful supervision and monitoring of the therapy is required as any change in symptoms may indicate relapsing arterial disease. If this occurs the compression bandages must be removed immediately and urgent vascular assessment sought.
Patients with diabetes mellitus are often prevented from receiving compression therapy. However, a diagnosis of diabetes should not preclude treatment with compression and it is essential that the correct cause and underlying aetiology of the ulcer is established. Compression should be used with caution in patients with peripheral neuropathy as they will not be aware of pressure-induced tissue damage.
Patients with rheumatoid arthritis often have venous disease, with an increased rate of venous refilling , poor ankle movement and reduced calf muscle-pump function. The protective function of four-layer bandaging can be helpful in such patients, particularly those who are highly susceptible to skin trauma as a result of dermal thinning due to the regular use of corticosteroids and those who have dependency oedema. Compression should be avoided in the small percentage of patients with vasculitis ulceration as this will exacerbate the failing microcirculation and can lead to extensive tissue necrosis .
Application of four-layer bandaging
A number of factors should be addressed before the application of four-layer bandaging (Box 3).
Box 3: Preparation for four-layer bandaging
Limb assessment: This should identify orthopedic problems, such as foot deformities or gait disturbance, which may require modification of the bandage application. The ankle circumference must be measured to ensure the correct combination of bandages is used and any change in the normal contour of the limb noted.
Wound assessment: Simple mapping or photography of the ulcer will provide a baseline to assess progress.
Pain assessment: Pain occurs in up to 80% of patients with venous ulceration but is often not assessed or treated appropriately . Pain reduces with compression, although a slight increase may occur during the first weeks of treatment , .
Wound contact material: Simple, non-adherent dressings that avoid trauma to both the wound and surrounding skin are recommended . Problems such as excessive exudate, odor and wound pain can be improved significantly by selecting appropriate wound dressings. Skin hydration remains a priority, as is the avoidance of products that may cause an allergic reaction.
Psychological preparation: Patients must be committed to receiving treatment and understand the significance of compression as the central treatment modality. Although many practitioners believe there is a low level of concordance with compression therapy, there is little evidence of this .
The methods used to apply four-layer bandaging have been described in numerous publications , . However, in reviewing the concepts underpinning the system it is important to examine the rationale for how the bandage should be applied and its adaptation for individual patient groups. Table 1 outlines the application issues relating to four-layer bandaging systems.
Table 1: Application of four-layer bandaging (ankle circumference 18-625px)
Redistributes pressure around limb
Orthopedic wool with varying levels of conformability and compressed thickness
Apply padding to base of toes. Pad tender area over dorsum of foot
Ensure Achilles tendon well covered
Ensure even application of 2 layers of padding
Use extra padding to protect bony prominences. Recon tour limb with loss of calf muscle. Avoid excessive padding which reduces pressure
Density and conformability of different products varies. Extra pad of foam over post malleolar area useful to increase pressure over ulcerated areas
Adds absorbency. Smooths orthopedic wool.
Preserves elastic energy (no compression)
Light support bandage. Unable to apply high levels of compression. Least effective layer
Bandage from base of toes using tension to ensure smooth surface on which to apply elastic layers
Cover all padding to avoid excessive bulk
Continue with 50% overlap up the limb
Second bandage not required unless excessively tall patient
Some 4 layer systems incorporate bandages with elastomeric fibers which may offer higher levels of pressure than cotton-based products. Check bandage specification
Elastic, extensible bandage
First layer of elastic compression sub-bandage (pressure at ankle17mmHg)
Light compression able to apply and maintain pressures up to approx. 20mmHg on ankle circumference (18-625px)
Begin extension from base of toes with 2 anchoring turns at 50% extension
Apply figure of 8 using a high and then low turn to avoid excess layers over dorsum of foot
Apply in a figure of 8 with 50% extension and overlap
Reduced pressure can be achieved by applying bandage in a spiral. Increased overlap will increase the pressure
Bandage extensibility ranges considerably within this group
Second layer of compression adds remaining 23mmHg of pressure. Cohesiveness retains bandage position
Cohesive, elastic bandage able to apply pressures up to approx. 25mmHg on ankle circumference (18-25 cm)
Applied in a spiral
Apply figure of 8 around ankle with a high and low turn. Avoid over- extension at front of foot
Bandage using 50% extension. 50% overlap using spiral technique
In 'champagne' shaped limbs with increased diameter use figure of 8 techniques. This can increase pressure and prevent slippage
Variations in extension possible.
Non-latex cohesive used in some systems
The careful design of the original Charring Cross four-layer and the newer Proofer systems were based on a thorough knowledge of the compression profiles of each bandage and of their combined effects. Although a number of multi-layer systems are described in the literature, it cannot be assumed that any combination of bandaging constitutes a four-layer system equivalent to the Charring Cross system. High compression bandages are available which, when used alone, can produce clinically effective levels of pressure, 35-40mmHg at the ankle. These bandages can, however, produce dangerously high levels of compression (>80mmHg) when used inappropriately .
Application over the foot
There is debate over whether elastic bandages should be applied at tension (force applied to fabric) over the foot. In the four-layer system, the elastic layers are applied with tension from the base of the toes. Failure to apply tension, and therefore equivalent pressure, over the foot can result in the rapid accumulation of edema over the dorsum of the foot. However, this may create a tourniquet effect around the ankle when extension is applied. Excessive pressure should be avoided and precautions must be taken in patients who are underweight or who have orthopedic foot deformities such as hallux valgus (bunion). Many patients develop lymphedematous changes of the toes. This can be managed by bandaging the toes with a light, mildly extensible cotton bandage.
Layer 1: orthopedic wool: Orthopedic wool provides a layer of padding that protects areas at risk of high pressure, such as the foot and ankle. Bandage slippage and pressure can result in damage to the Achilles tendon so this area must be well protected. The tibia crest is often subjected to high levels of pressure, with evidence of pressure damage on bandage removal. Patients with thin limbs are particularly vulnerable, as are men with a prominent tibia crest and little overlying subcutaneous tissue. Simple methods such as pleating the orthopedic wool or the addition of a strip of wool over the area can provide extra protection. Due to the increased skin sensitivity in venous disease, the padding layer should cover all vulnerable areas and just be visible at the toes and top of the bandage.
The addition of a light cotton tubular bandage next to the skin may also offer protection to patients who are prone to varicose eczema.
Layer 2: crepe bandage: This is the least effective layer as it simply adds extra absorbency and smooths down the orthopedic layer prior to the application of the two outer compression bandages.
Layer 3: elastic extensible bandage: This is the first of the two outer elastic bandages. It is a highly extensible bandage that provides a sub-bandage pressure of approximately 17mmHg when applied at 50% extension with a 50% overlap using a figure-of-eight technique. In 'champagne’ shaped limbs the figure-of-eight application can be widened to aid conformability. If greater pressure is required over an edematous calf, this can be achieved in the following ways:
Increasing bandage extension, although care must be taken not to exert too much pressure
Adding additional layers of bandage.
Similarly, in patients with thin limbs the pressure can be reduced by decreasing bandage extension. The wide extensibility curve (ability to stretch) in these bandages allows for flexibility on application, but again practitioners must take care not to decrease the pressure to an ineffective level.
Layer 4: elastic cohesive bandage: A frequent misconception is that the outer cohesive layer within the four-layer system is there simply to maintain the bandage position. In fact, this layer provides the higher level of compression (sub-bandage pressure approximately 23mmHg) and must not be over-extended. Bandaging should extend over the upper portion of the gastrocnemius muscle to prevent slippage. The cohesive layer should not be applied in direct contact with the skin because of the risk of latex allergy. Some systems incorporate a latex-free outer layer. The two outer elastic bandages, when used in combination, provide a sub-bandage pressure of approximately 40mmHg.
Modifying the four-layer bandage system
The pressure generated by a bandage is determined principally by the tension in the fabric, the number of layers applied and the degree of curvature of the limb. The relationship between these factors is governed by Laplace's law , which states that the applied pressure is directly proportional to the tension in the bandage but inversely proportional to the radius of the curvature of the limb to which it is applied. The natural cone shape of the lower limb is therefore a major factor in achieving a correct pressure gradient . Where the patient's ankle circumference or limb shape is outside the normal range, modifications can be made to the system to achieve adequate sub-bandage pressures (Table 2). Thin limbs with a circumference of less than 450px require additional padding to increase protection and artificially increase the circumference of the limb. In cases where the ankle circumference is greater than 625px, a therapeutic level of compression is rarely achieved. In these patients, the elastic bandages are substituted for those with a higher elastic modules (power). Care should be taken with these bandages to ensure correct bandage extension, using bandage application guides or symbols, when present, to aid this process. The patient's limb should be regularly measured as rapid loss of edema may occur in the first few weeks of treatment, reducing the ankle circumference.
Table 2: Modifications to the four-layer bandage system based on ankle circumference (sub-bandage pressure of approximately 40mmHg applied to all limbs)
Ankle circumference less than 450px
2 or more orthopedic wool
1 elastic conformable
1 elastic cohesive
Ankle circumference 18-625px
1 orthopedic wool
1 elastic conformable
1 elastic cohesive
Ankle circumference 25-750px
1 orthopedic wool
1 high compression bandage (approximate pressure 35mmHg*)
1 elastic cohesive
Ankle circumference >750px
1 orthopedic wool
1 elastic conformable
1 high compression bandage (approximate pressure 35mmHg*)
1 elastic cohesive
* Increase in ankle circumference reduces sub-bandage pressure applied.
Reproducibility of graduated compression profiles
Evidence accumulated over the past decade suggests that there are wide variations in the gradient and level of compression applied by different bandages. This is despite simplistic classifications describing their use . In addition, individual practitioners may produce very different compression profiles when bandaging the same patient using the same bandage technique but with different products . This reinforces the need for appropriate training in the art of bandaging as well as an understanding of the scientific principles .
During the development stage of the four-layer bandage, extensive pressure monitoring studies revealed the system's ability to maintain pressure over time and that the pressures achieved were highly reproducible in a range of patients using different methods of application . This compared starkly with the bandages in use at the time, such as elastic crepe and elastic plast, which had reduced sub-bandage pressures within a few hours that fell below a therapeutic level.
Research has begun to examine the dynamic effects of compression during exercise and in different limb positions . These issues may be important in examining how compression works in complex patient populations. A number of authors have demonstrated that fluctuations in pressure occur during exercise . Partech noted that four-layer bandaging was associated with a rise in pressure of up to 45mmHg during walking, but at rest the pressure did not fall below 40mmHg .
A study comparing two multi-layer bandage systems found that variations in pressure were related to the position in which the patient was bandaged . Those bandaged in a sitting position with a 90-degree angle at the knee had accurate gradients of pressure, compared with those bandaged in a semi-recumbent position where the calf pressure fell when the patient changed to a sitting position. This is probably due to changes in the calf circumference during contraction and relaxation of the calf muscle. The pressures at the knee and ankle were similar to those achieved in the semi-recumbent position.
While of interest, it remains unclear whether minor variations in sub-bandage pressure associated with changes in position are of clinical importance . The issue is further complicated by the difficulties associated with pressure measurement and the variations between different application techniques .
It is important to fully assess patients prior to the application of four-layer bandaging. This will confirm the presence of venous disease and suitability for treatment; failure to identify arterial disease will result in the unsafe application of compression therapy. To achieve optimum levels of compression, practitioners require appropriate training, an understanding of the method of application and how this can be modified to suit individual patient groups.
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