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Chronic venous diseases (CVD), including venous leg ulcers (VLU), represent a significant health burden. Despite the central role of compression therapy in current treatment guidelines, recent evidence suggests substantial gaps in provision. A retrospective cohort study was conducted using anonymized claims data from 3.35 million insured individuals. Persons with VLU or CVD in 2017 were observed over 5 years. Compression therapy, comorbidities, antibiotic prescriptions, and physician contacts were analysed. The prevalence was 0.50% for VLU (n = 16 615) and 7.27% for CVD (n = 243 681). Across 5 years, 75.85% (VLU) and 53.10% (CVD) received compression therapy. However, 24.15% of persons with VLU were not treated with compression therapy. Persons receiving compression were predominantly female and older (VLU: 74.13 years, 59.56% women; CVD: 68.55 years, 70.86% women), exhibited a higher mean Charlson Comorbidity Index (CCI [95% CI]: VLU 4.09 [4.03-4.15], CVD 2.67 [2.65-2.68] vs. VLU 3.14 [3.05-3.23], CVD 2.12 [2.11-2.14] without compression). In the first year post-diagnosis, 51.43% VLU persons with compression received antibacterials (vs. 36.28%). The data confirm prior estimates of disease prevalence and highlight a substantial gap in the documented use of guideline-compliant compression therapy, especially in VLU. High multimorbidity and care intensity underscore the need for better integration of compression therapy in routine practice.