Compression therapy: Unna boot applied to venous injuries: an integrative review of the literature

Cardoso, Luciana Ventura; Godoy, José Maria Pereira de; Godoy, Maria de Fátima Guerreiro; Czorny, Rildo César Nunes

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Revista da Escola de Enfermagem da USP

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Review Article • Rev. esc. enferm. USP 52 • 2018 • https://doi.org/10.1590/S1980-220X2017047503394 copy

Compression therapy: Unna boot applied to venous injuries: an integrative review of the literature

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To analyze the literature related to the types of therapies for venous injuries with emphasis on use of the Unna boot, and to investigate and discuss the main aspects related to its use compared to other techniques.

Method:

Integrative review of the literature of the last five years through searches in the following databases: VHL, LILACS, BDENF, SciELO, MEDLINE/PubMed.

Results:

Twenty-two publications were identified, with 15,931 cases among adult or elderly individuals, whose mean age was 60 (35-78) years or greater with no sex differences. The Unna boot presented a shorter healing time than the single and two-layer elastic bandage.

Conclusion:

Although other compression techniques may prove to be more efficient than the Unna boot by adding more technology, the boot stands out as a traditional low-cost dressing. Multilayer bandage is a gold standard technique. This review demonstrated the best option may not be the Unna boot, because it requires a higher healing time compared to the multilayer bandage, but it meets the expectation with a high rate of treatment efficiency, also when compared to simple dressing, single or two-layer bandage.

DESCRIPTORS
Leg Ulcer; Varicose Ulcer; Venous Insufficiency; Compression Bandages; Wound Healing; Review

Database	Language	Crossings
BDENF, LILACS, MEDLINE, SciELO	English	boot AND unna OR varicose ulcer/therapy OR compression therapy venous leg
		unna boot AND varicose ulcer/therapy AND compression therapy venous leg
		unna boot AND varicose ulcer/therapy OR compression therapy venous leg
		unna boot OR varicose ulcer/therapy AND compression therapy venous leg
	Portuguese	bota AND unna OR Ulcera varicosa/terapia OR Terapia compressiva venosa na perna
		bota unna AND Ulcera varicosa/terapia AND Terapia compressiva venosa na perna
		bota unna AND Ulcera varicosa/terapia OR Terapia compressiva venosa na perna
		bota unna OR Ulcera varicosa/terapia AND Terapia compressiva venosa na perna
	Spanish	bota AND unna OR Ulcera varicosa/terapia OR Terapia compresiva venosa en la pierna
		bota unna AND Ulcera varicosa/terapia AND Terapia compresiva venosa en la pierna
		bota unna AND Ulcera varicosa/terapia OR Terapia compresiva venosa en la pierna
		bota unna OR Ulcera varicosa/terapia AND Terapia compresiva venosa en la pierna
		bota unna AND Ulcera varicosa/terapia AND Terapia compresiva venosa en la pierna
		bota unna AND Ulcera varicosa/terapia OR Terapia compresiva venosa en la pierna
		bota unna OR Ulcera varicosa/terapia AND Terapia compresiva venosa en la pierna
PubMed	English	boot[All Fields] AND unna[All Fields]) OR “varicose ulcer/therapy”[Mesh Terms]) OR (compression[All Fields] AND (“therapy”[Subheading] OR “therapy”[All Fields] OR “therapeutics”[MeSH Terms] OR “therapeutics”[All Fields]) AND (“veins”[MeSH Terms] OR “veins”[All Fields] OR “venous”[All Fields]) AND (“leg”[MeSH Terms] OR “leg”[All Fields]
		unna[All Fields] AND boot[All Fields]) AND “varicose ulcer/therapy”[Mesh Terms]) AND (compression[All Fields] AND (“therapy”[Subheading] OR “therapy”[All Fields] OR “therapeutics”[MeSH Terms] OR “therapeutics”[All Fields]) AND (“veins”[MeSH Terms] OR “veins”[All Fields] OR “venous”[All Fields]) AND (“leg”[MeSH Terms] OR “leg”[All Fields]
		unna[All Fields] AND boot[All Fields]) AND “varicose ulcer/therapy”[Mesh Terms]) OR (compression[All Fields] AND (“therapy”[Subheading] OR “therapy”[All Fields] OR “therapeutics”[MeSH Terms] OR “therapeutics”[All Fields]) AND (“veins”[MeSH Terms] OR “veins”[All Fields] OR “venous”[All Fields]) AND (“leg”[MeSH Terms] OR “leg”[All Fields]

Author and year	Study Design; period and country	Sample	Prevailing age	Sex (%)	Results
Luz (2013)⁽¹⁸18. Luz BSR, Araujo CS, Atzingen DANCV, Mendonca ARA, Mesquita Filho M, Medeiros ML. Evaluating the effectiveness of the customized Unna boot when treating patients with venous ulcers. An Bras Dermatol. 2013;88(1):41-9.⁾	Longitudinal, prospective, exploratory and quantitative; 2008; Brazil	32	> 60	F= 65 M= 35	The Unna boot accelerated healing, but compared to the simple dressing had equal efficiency. Contrary to what is expected in the literature, the author considers this result is a consequence of the high rate of patients’ absence in assessments.
Salomé (2012)⁽²⁵25. Salomé GM, Ferreira LM. Qualidade de vida em pacientes com úlcera venosa em terapia compressiva por bota de Unna. Rev Bras Cir Plast. 2012;27:466-71.⁾	Clinical, descriptive and analytical trial; 2010-2011; Brazil	50	> 60	F= 52 M= 48	After eight months with the Unna boot, 84% of injuries healed, and patients showed improvement in their quality of life indexes.
Sant'ana (2012)⁽²⁶26. Sant'Ana SMSC, Bachion MM, Santos QR, Nunes CAB, Malaquias SG, Oliveira BGRB. Úlceras venosas: caracterização clínica e tratamento em usuários atendidos em rede ambulatorial. Rev Bras Enferm. 2012;65(4):637-44.⁾	Descriptive, cross-sectional and quantitative; 2009-2010; Brazil	58	≥ 50	F= 33 M= 67	Low use of the Unna boot (3.9%), treatment in disagreement with international recommendations (wound cleaning), need for multiprofessional intervention and effective accountability of nurses in the wound dressing room.
Lima (2013)⁽²⁷27. Lima EL, Rocha MJAB, Ferreira LM. The impact of compression therapy with Unna's boot on the functional status of VLU patients. J Wound Care. 2013;22(10):558-61.⁾	Analytical, case-control; 2010-2011; Brazil	50	> 60	F= 52 M= 48	After eight months using the Unna boot, there was improvement in patients’ functional capacity score for performing daily activities and in clinical and sociodemographic characteristics.
Scotton (2014)⁽²⁸28. Scotton MF, Miot HA, Abbade LPF. Factors that influence healing of chronic venous leg ulcers: a retrospective cohort. Anais Bras Dermatol. 2014;89(3):414-22.⁾	Cohort and retrospective; 2000-2010; Brazil	94	≥ 60	F= 72 M= 28	The Unna boot was used in 40% of the sample, but the evidence was not enough to determine what provided its benefit. Poor use of compression therapy and prolonged duration of antibiotic use were correlated with poor prognosis for cure. Multilayer compression (gold standard) was not available in the Brazilian health system – SUS (study site) for comparison.
Santos (2015)⁽²⁹29. Santos FTA, Rocha CA, Cunha SXS, Santos TFA, Melo Junior CH, Lima JMB et al. Tissue characterization by photographic imaging during treatment of chronic venous ulcer: technical note. J Vasc Bras. 2015;14(2):177-81.⁾	Case report; 45 days; Brazil	1	35	F= 1 M= 0	Quantified the photographic evolution of healing according to the tissue injury characterization by comparing the aspect of the adjacent skin. With use of the Unna boot, the ulcer brightness increased from 110 to 159 pixels and reached 203 post-healing. The edge of the ulcer had an increase from 117 to 137 pixels post-healing.
Abreu (2015)⁽³⁰30. Abreu AM, Oliveira BGRB. A study of the Unna Boot compared with the elastic bandage in venous ulcers: a randomized clinical trial. Rev Latino Am Enfermagem. 2015;23(4):571-7.⁾	Clinical, controlled and randomized trial; 2011; Brazil	19	≥ 55	F= 42 M= 58	The Unna boot was the best product compared to the use of elastic bandage for reduction of injury area and of exudate. In greater wounds, elastic therapy showed results only after the fifth week. In both options, there was improvement of the injury, pain and edema. The recommendation was to change the secondary dressing daily for preventing odor (Unna boot), and the elastic bandage should be removed before bedtime and replaced in the morning.
Pereira (2016)⁽³¹31. Pereira BEM, Sousa ATO, Franca JRFS, Soares MJGO. Cost comparison of three kinds of compression therapy in venous ulcer. Anais Bras Dermatol. 2016;91(4):544-6.⁾	Case report; 63 days; Brazil	3	≥ 50	F= 1 M= 2	The single-layer elastic bandage was more cost effective and reduced healing time. Savings of 82% compared to multilayer. The ulcer with greater diameter (210 cm²) reduced by 22.2% with multilayer bandage in only 62 days (faster), in addition to reducing pain and improving mobility. Elastic therapy seemed to be more effective than the Unna boot (time).
Lima, (2014)⁽³²32. Lima MSFS, Carvalho ESS, Gomes WS. Diagnósticos de enfermagem em mulheres usuárias de bota de Unna. Rev Baiana Enferm; 2014;28(2):156-67.⁾	Qualitative; 2013; Brazil	8	N.I.	F= 8 M= 0	People have many expectations about the effects of the Unna boot. The successes of therapy make women more optimistic, while failures lead to hopelessness. This indicates that nurses must identify biopsychosocial aspects, nursing diagnoses and implement measures for improving the quality of life.
Danski, (2016)⁽³³33. Danski MTR, Liedke DCF, Vayego SA, Pontes L, Lind J, Johann DA et al. Tecnologia bota de Unna na cicatrização da úlcera Cogitare Enferm. 2016;21(3):1-9.⁾	Descriptive retrospective; 2007-2012; Brazil	49	57	F= 21 M= 28	After analyzing the medical charts, among patients who used the Unna Boot, the therapy was efficient in healing varicose ulcers in up to 12 weeks, especially those of small size. The size of the ulcer, presence of purulent exudate, intense volume of exudate and unaided ambulation were variables that interfered in healing. Application of the Unna boot after healing for 3-4 week periods was beneficial for preventing relapses.
Abreu, (2013)⁽¹⁹19. Abreu AM, Oliveira BGRB, Manarte JJ. Tratamento de úlcera venosa com bota de Unna: estudo de caso. Online J Issues Nurs. 2013;12(1):198-208.⁾	Case report; 2 months; Brazil	1	64	F= 0 M= 1	The use of the Unna boot was effective in healing, reduction of pain, reduction of exudate and pruritus, hydration of the wound bed and edema. The nurse should focus on the prevention of new wounds and self-care practices with the injury. The importance of outpatient follow-up of patients by health professionals, including nurses and angiologists, was highlighted. Lack of patients’ adherence to treatment may compromise tissue repair results. The use of elastic stockings should be indicated to avoid relapses.
Lullove, (2014)⁽³⁴34. Lullove EJ, Newton E. Use of a novel two-layer bandage in the treatment of chronic venous hypertension. J Am Col Certif Wound Spec. 2013;5(1):8-13.⁾	Cohort and retrospective; 2000-2013; USA	60	≥ 75	F= 55 M= 45	The two-layer Unna boot (Andover) improved all symptoms, demonstrated effectiveness for reduction of edema and wound size after 12 weeks, and improved adherence to treatment compared to no compression therapy. Professional qualification was emphasized as being fundamental.
Fox (2016)⁽³⁵35. Fox JD, Baquerizo-Nole KL, Freedman JB, Liu S, Van Driessche F, Yim E et al. Ankle Range of Motion, Leg Pain, and Leg Edema Improvement in Patients With Venous Leg Ulcers. JAMA Dermatol. 2016;152(4):472-4.⁾	Prospective and observational; 28 days; USA	10	N.I.	F= 5 M= 5	The use of multilayer therapy reduced leg circumference and was associated with improved inversion/eversion. There was also improvement in total plantar dorsiflexion associated with leg pain and wound pain. These findings were not correlated with the percentage wound reduction.
Pham, (2012)⁽³⁶36. Pham B, Harrison MB, Chen MH, Carley ME. Cost-effectiveness of compression technologies for evidence-informed leg ulcer care: results from the Canadian Bandaging Trial. BMC Health Serv Res. 2012;12:346-54.⁾	Comparative analysis; 2009-2010; Canada	424	N.I.	N.I.	The findings differ from emerging clinics and economic evidence supporting the four-layer high compression therapy, and thus suggest another perspective on high compression practice. That is, when applied by trained nurses based on evidence and protocol, four and two-layer bandages offer comparable cost-effectiveness and monetary value.
Dabiri, (2015)⁽³⁷37. Dabiri G, Hammerman S, Carson P, Falanga V. Low-grade elastic compression regimen for venous leg ulcers--an effective compromise for patients requiring daily dressing changes. Int Wound J. 2015;12(6):655-61.⁾	Clinical trial – non-randomized – open, 14 weeks; USA	7	≥ 56	F= 3 M= 4	A latex free compression tubular elastic bandage with double layer was tested. There was an increase in the healing rate with use of the tubular material. All individuals have shown healing at the 4^th and 8^th week. The conclusion was that tubular elastic compression can be used safely in patients with venous leg ulcers. This type of therapy allows for the daily inspection of the wound, getting dressed, and is an option among conventional compression therapies.
Dolibog (2014)⁽³⁸38. Dolibog P, Franek A, Taradaj J, Dolibog P, Blaszczak E, Polak A et al. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. J Int Assoc Med Sci Educ. 2014;11(1):34-43.⁾	Prospective, randomized and comparative; 2010-2013; Poland	117	> 60	F= 66 M= 34	Pneumatic system, stocking and multilayer bandage showed efficiency compared to two-layer bandage and Unna boot.
Dolibog (2013)⁽³⁹39. Dolibog PFA, Taradaj J, Polak A, Dolibog P, Blaszczak E, Wcislo L et al. A randomized, controlled clinical pilot study comparing three types of compression therapy to treat venous leg ulcers in patients with superficial and/or segmental deep venous reflux. 2013. Ostomy Wound Manage. 2013;59(8):22-30.⁾	Prospective, randomized and clinical; 2010-2012; Poland	70	> 60	F= 56 M= 44	Pneumatic compression system was more efficient than stockings and compression bandage.
Petherick (2013)⁽⁴⁰40. Petherick ES, Cullum NA, Pickett KE. Investigation of the effect of deprivation on the burden and management of venous leg ulcers: a cohort study using the THIN Database. PLoS One. 2013;8(3):e58948.⁾	Cohort and prospective; 2001-2006; United Kingdom	14.000	> 70	F= 63 M= 37	Low use of the Unna boot (<16%): socioeconomic gradient in disease, social inequality negatively associated with Doppler access and poor patient orientation on the disease.
Adderley (2014)⁽⁴¹41. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.⁾	Open, randomized pragmatic clinical trial; 12 months; United Kingdom	454	N.I.	N.I.	The two-layer compression stocking and the four-layer bandage were compared. There was no significant difference between the average healing time. Average costs were around £300 per participant per year. Those who used stockings needed fewer nursing appointments. The findings suggest that stockings have a 95% chance of being more cost effective than four-layer bandage.
Finlayson (2014)⁽⁴²42. Finlayson KJ, Courtney MD, Gibb MA, O’Brien JA, Parker CN, Edwards HE. The effectiveness of a four-layer compression bandage system in comparison with Class 3 compression hosiery on healing and quality of life in patients with venous leg ulcers: a randomised controlled trial. Intern Wound J. 2014;11(1):21-7.⁾	Randomized and controlled; 2006-2009; Australia	103	≥ 60	F= 50 M=50	Compression systems were equally effective after 24 weeks, but the four-layer system response was faster. There was no difference in results of quality of life and pain. The injury size and the time of open wound influenced the prognosis.
So (2014)⁽⁴³43. So WKW, Wong IKY, Lee DTF, Thompson DR, Lau YW, Chao DVK et al. Effect of compression bandaging on wound healing and psychosocial outcomes in older people with venous ulcers: a randomized controlled trial. Hong Kong Med J. 2014;20 Suppl 7:40-1.⁾	Randomized; N.I.; Hong Kong	321	≥ 60	N.I.	Compression is not known to nurses. Healing increases with compression compared to its absence. The efficacy of four-layer compared to single-layer was not determined. After the test of single-layer, no compression, and four-layer, the conclusion was that compression reduces the size of the ulcer and also acts on pain.
Zarchi, (2014)⁽⁴⁴44. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.⁾	Cross-sectional study; 2011-2012; New Zealand	–	–	–	Compression was compared, indicating that many do not receive adequate therapy. When applying the inelastic bandage, there was a disparity among nurses in relation to obtaining the ideal pressure. However, application of the two-component compression bandage led to a considerably higher mean pressure (41.9 mmHg pressure) compared to the others. Suggestion to conduct training in the area, since the time of experience in the sector did not guarantee the proper application of the technique.

Authors	Patients/Total sample	Material	Results
Authors	Patients/Total sample	Material	HR (%)	RWR (%)
Dolibog et al., 2013⁽³⁸38. Dolibog P, Franek A, Taradaj J, Dolibog P, Blaszczak E, Polak A et al. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. J Int Assoc Med Sci Educ. 2014;11(1):34-43.⁾	SVR: 12	IP	SVR: 25.0	SVR: 41.2
	DVR: 10		DVR: 20.0	DVR: 38.7
	AVR: 12
	SVR: 11	Stocking	SVR: 27.3	SVR: 42.1
			DVR: 6.0	DVR: 15.9
			AVR: 20.0	AVR: 39.2
	SVR: 10	EB – 2 layers	SVR: 10.0	SVR: 18.8
	DVR: 15	EB – 2 layers	SVR: 10.0	SVR: 18.8
Dolibog et al., 2014⁽³⁹39. Dolibog PFA, Taradaj J, Polak A, Dolibog P, Blaszczak E, Wcislo L et al. A randomized, controlled clinical pilot study comparing three types of compression therapy to treat venous leg ulcers in patients with superficial and/or segmental deep venous reflux. 2013. Ostomy Wound Manage. 2013;59(8):22-30.⁾	17/29	MB	58.6	–
	16/28	IP	57.1	–
	17/30	Stocking	56.7	–
	6/30	Unna boot	20.0	–
	5/30	EB – 2 layers	16.7	–
Abreu et al., 2015⁽³⁰30. Abreu AM, Oliveira BGRB. A study of the Unna Boot compared with the elastic bandage in venous ulcers: a randomized clinical trial. Rev Latino Am Enfermagem. 2015;23(4):571-7.⁾	9/18	Unna boot	–	69.4
	9/18	Elastic bandage	–	42.3
Adderley U, 2014⁽⁴¹41. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.⁾	224/454	EB – 4 layers	71.0	–
	230/454	Stocking – 2 layers	70.0	–
So et al., 2014⁽⁴³43. So WKW, Wong IKY, Lee DTF, Thompson DR, Lau YW, Chao DVK et al. Effect of compression bandaging on wound healing and psychosocial outcomes in older people with venous ulcers: a randomized controlled trial. Hong Kong Med J. 2014;20 Suppl 7:40-1.⁾	NA/321	EB – 4 layers	–	85.8
		EB – single	–	86.3
		No compression	–	33.5

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E-mail: reeusp@usp.br

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[1] Corresponding author: Luciana Ventura Cardoso, Av. Constituição, 1306, Boa Vista, CEP 15025-120 – São José do Rio Preto, SP, Brazil lu_famerp@hotmail.com