Compression therapy is the oldest and until recently the only therapeutic option available to treat PTS. It has been reported anecdotally to be ineffective in PTS but no systematic study has been undertaken. Compression therapy remains the initial approach in chronic venous disease including PTS. Some patients do fail compression therapy despite faithful compliance. Noncompliance, however, is the major cause of compression failure and recurrent symptoms.27-29 Noncompliance is high even in cold climates as documented in several community surveys. Long-term supervision or monitoring by health care workers has been advocated to improve compliance. However, noncompliance is high even under supervision.29,30 The reasons for noncompliance are many—tightness or fit (cutting off circulation), warm weather, lack of efficacy, contact dermatitis, recurrent cost and inability to apply stockings due to frailty or arthritis are among the many reasons/excuses cited by patients. But the main underlying reason, often unstated, appears to be the restrictions and negatives of compression regimens in today's image-conscious world with expectations of an unrestricted lifestyle. Thus compression is a quality of life issue from the patient's viewpoint. Demands for compliance are unlikely to succeed after previous entreaties have failed and may not be appropriate when therapeutic alternatives have become available. Compression should be viewed not as an end itself, but complementary to the extent patients are willing to use them. Compression should be considered a failure regardless of the cause including non-compliance if symptom relief is not obtained after trial over a reasonable period of time, say three to six months depending on the clinical and socioeconomic situation of the patient. Worsening of symptoms or onset of complications such as recurrent infections during the trial period are also considered failures. Some patients are not candidates for compression therapy at all due to comorbidities (e.g., arthritis, frailty, or arterial compromise)31 or special work situations. Nonre-sponders should be offered alternatives, not life-long unna boot regimens as was the case before by necessity, and continues to be so in many parts of the world due to a conservative philosophy of health care delivery.
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