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

Luciana Ventura Cardoso José Maria Pereira de Godoy Maria de Fátima Guerreiro Godoy Rildo César Nunes Czorny About the authors

RESUMO

Objetivo:

Analisar a bibliografia relacionada aos tipos de terapias para lesões venosas, enfatizando o uso da bota de Unna, e investigar e discutir os principais aspectos relacionados ao seu uso, comparados aos de outras técnicas.

Método:

Revisão integrativa da literatura dos últimos 5 anos, por meio de buscas na BVS, LILACS, BDENF, SciELO, MEDLINE/PubMed.

Resultados:

Foram identificadas 22 publicações, com 15.931 casos entre adultos ou idosos, cuja média de idade foi igual ou superior a 60 (35-78) anos, sem discrepância na porcentagem de gênero. A bota de Unna apresentou um tempo inferior de cicatrização que a bandagem elástica simples e de duas camadas.

Conclusão:

Embora outras técnicas compressivas possam mostrar-se mais eficientes do que a bota de Unna, por agregar mais tecnologia, a bota se destaca por ser um curativo tradicional de baixo custo. A bandagem multicamada é uma técnica padrão-ouro. Esta revisão mostrou que a bota de Unna pode não ser a melhor opção, por demandar um tempo superior de cicatrização em comparação à bandagem multicamada, mas atende à expectativa com um alto índice de eficiência no tratamento, ainda se comparada ao curativo simples, bandagem simples ou de duas camadas.

DESCRITORES
Úlcera da Perna; Úlcera Varicosa; Insuficiência Venosa; Bandagens Compressivas; Cicatrização; Revisão

RESUMEN

Objetivo:

Analizar la bibliografía relacionada con los tipos de terapias para lesiones venosas, subrayando el empleo de la bota de Unna, e investigar y discutir los principales aspectos relacionados con el uso, comparados con los de otras técnicas.

Método:

Revisión integrativa de la literatura de los últimos cinco años, mediante búsquedas en la BVS, LILACS, SciELO, MEDLINE/PubMed.

Resultados:

Fueron identificadas 22 publicaciones, con 15.931 casos entre adultos o añosos, cuyo promedio de edad fue igual o superior a 60 (35-78) años, sin discrepancia en el porcentaje de género. La bota de Unna presentó un tiempo inferior de cicatrización que el vendaje elástico simple y de dos capas.

Conclusión:

Aunque otras técnicas compresivas puedan mostrarse más eficientes que la bota de Unna, por agregar más tecnología, la bota se destaca por ser un apósito tradicional de bajo costo. El vendaje multicapa es una técnica regla de oro. Esta revisión mostró que la bota de Unna puede no ser la mejor opción, al demandar un tiempo superior de cicatrización en comparación con el vendaje multicapa, pero atiende a la expectación con un alto índice de eficiencia en el tratamiento, incluso si comparada con el apósito simple, vendaje simple o de dos capas.

DESCRIPTORES
Ulcera de la Pierna; Ulcera Varicosa; Insuficiencia Venosa; Vendajes de Compresión; Cicatrización de Heridas; Revisión

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

INTRODUCTION

The incidence of venous insufficiency (VI) of the lower limbs (LL) has significant worldwide growth, mainly due to longevity(11. Cavalcante AMRZ, Moreira A, Azevedo KB, Lima LR, Coimbra WKAM. Diagnóstico de enfermagem: integridade tissular prejudicada identificado em idosos na Estratégia de Saúde da Família. Rev Eletr Enf. 2017;12(4):727-35. DOI: http://dx.doi.org/10.5216/ree.v12i4.8425
http://dx.doi.org/10.5216/ree.v12i4.8425...
). This condition is characterized by partial or complete mechanical obstruction (thrombosis) that results in valve insufficiency and venous hypertension by causing instability between the flow and reflux in blood vessels. The following are among the main risk factors: diabetes, hypertension, obesity, traumas and smoking, as well as the female sex by the number of pregnancies or use of contraceptive medication(22. Sociedade Brasileira de Angiologia e de Cirurgia Vascular Regional de São Paulo. Insuficiência venosa crônica/varizes dos membros inferiores [Internet]. São Paulo; 2015 [citado 2017 mar. 24]. Disponível em: https://sbacvsp.com.br/insuficiencia-venosa-cronica-varizes-dos-membros-inferiores/
https://sbacvsp.com.br/insuficiencia-ven...
). Once the disease establishes, it can progress to wounds of difficult healing, incapacities, and still recur in up to 66% by making the condition chronic(33. Carmo SS, Castro CD, Rios VS, Sarquis MGA. Atualidades na assistência de enfermagem a portadores de úlcera venosa. Rev Eletr Enf [Internet]. 2007 [citado 2017 mar. 24]; 9(2): 506-517. Disponível em: https://www.fen.ufg.br/revista/v9/n2/pdf/v9n2a17.pdf
https://www.fen.ufg.br/revista/v9/n2/pdf...
). Feeling of weight, pain and itching in the lower limbs (LL)(44. Seidel AC, Campos MB, Campos RB, Harada DS, Rossi RM, Cavalari Junior P, et al Associação entre sintomas, veias varicosas e refluxo na veia safena magna ao eco-Doppler. J Vasc Bras [Internet]. 2017 [citado 2017 jul. 24];16(1):4-10. Disponível em: http://www.scielo.br/scielo.php?pid=S1677-54492017000100004&script=sci_abstract&tlng=pt
http://www.scielo.br/scielo.php?pid=S167...
) are often diagnosed clinical symptoms, and may be supplemented with Doppler-like imaging tests.

Venous ulcer is a prevalent disease in industrialized countries. The estimate is that 1% of the adult population may be affected by it(55. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2005;111(18):2398-409.). In the United States, 6.5 million people are affected each year, which generates a cost of 3 billion annually to the health sector(66. Aldunate JLCB, Isaac C, Ladeira PRS, Carvalho VF, Ferreira MC. Úlceras venosas em membros inferiores. Rev Med USP. 2010;89(3/4):158-63.). One of the main forms of prevention is maintaining proper eating habits, performing physical activity, raising legs above heart level for approximately 20 minutes, and wearing compressed elastic stockings as recommended by a trained health professional.

The main complication of chronic venous insufficiency is venous ulcer, which usually manifests in the lower third (malleolus) of the lower limbs, and healing can progress from six weeks to several years(77. Piropo T, Gomes F, Azoubel R, Torres G. Autocuidado de portadores de úlcera venosa crônica em ambiente domiciliar. Saude [Internet]. 2016 [citado 2017 jul. 02];8(2)2-11. Disponível em: http://www.uesb.br/revista/Rsc/ojs/index.php/rsc/article/view/165
http://www.uesb.br/revista/Rsc/ojs/index...
). Venous ulcers are usually superficial, but depending on the picture, they go through various levels of aggravation. Stage I presents erythema, but the skin remains intact. In stage II, the skin loses thickness, and the dermis is exposed. In stage III, there is total loss of skin. In stage IV, there is total tissue loss, and the deep tissue region assumes a dark red, brown or purple color(88. Associação Brasileira de Estomaterapia; Associação Brasileira de Enfermagem em Dermatologia. Classificação das lesões por pressão – consenso NPUAP 2016 [Internet]. 2017 [citado 2017 mar. 13]. Disponível em: http://www.sobest.org.br/textod/35
http://www.sobest.org.br/textod/35...
99. Brito CKD, Cardoso NI, Victor JF, Feitoza SMS, Silva MG, Amaral HEG. Úlcera venosa: avaliação clinica, orientações e cuidados com o curativo. Rev Rene. 2013;14(3):470-80.).

Venous ulcer is one of the most relevant public health problems, especially in the Western Hemisphere(1010. Lopes CR, Figueiredo M, Ávila A, Soares LMBM, Dionisio VC. Avaliação das limitações de úlcera venosa em membros inferiores. J Vasc Bras [Internet]. 2013 [citado 2017 Set 19];12(1):5-9. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1677-54492013000100003&lng=en. http://dx.doi.org/10.1590/S1677-54492013000100003
http://www.scielo.br/scielo.php?script=s...
), with prevalence of 80% to 85%, and the rest of the wounds are diagnosed as arterial, mixed or neuropathic(1111. Dargaville TR, Farrugia BL, Broadbent JA, Pace S, Upton Z, Voelcker NH. Sensors and imaging for wound healing: a review. J Biosens Bioelectron. 2013;41:30-42.). In the United States, there are 2.5 million and in the United Kingdom there are approximately 580,000 individuals with wounds, which result in costs between 300 and 600 thousand pounds with health professionals(1212. Baptista CMC, Castilho V. Levantamento do custo do procedimento com bota de Unna em pacientes com úlcera venosa. Rev Lat Am Enfermagem. 2006;14(6):944-9.). In addition to the physical impact of chronic injuries on people, and the burden of material and human resources, there is psychosocial involvement(1313. Silva MAM, Burihan MC, Barros OC, Nasser F, Ingrund JC, Neser A. Resultados do tratamento da Insuficiência Venosa Crônica grave com espuma de polidocanol guiada por ultrassom. J Vasc Bras. 2012;11(3):207.). In Brazil, it is estimated that 3% of the population has vascular injury in LLs, and it can reach 10% if the individual is affected by diabetes mellitus(1414. Macedo EAB, Oliveira AKA, Melo GSM, Nóbrega WG, Costa IKF, Dantas DV et al. Caracterização sócio-demográfica dos pacientes com úlcera venosa atendidos em um hospital universitário. Rev Enferm UFPE on line [Internet]. 2010 [citado 2011 abr. 20];4 Supl:1863-7 [citado 2011 abr. 20]. Disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/6375
https://periodicos.ufpe.br/revistas/revi...
). In Europe, one in every 1,000 people have the disease. It is common in the elderly, and about 20 out of 1,000 people acquire the disease after reaching the eighth decade of life(1515. Fonseca C, Franco T, Ramos A, Silva C. A pessoa com úlcera de perna, intervenção estruturada dos cuidados de enfermagem: revisão sistemática da literatura. Rev Esc Enferm USP [Internet]. 2012 [citado 2017 set. 19];46(2):480-6. Disponível em: http://www.scielo.br/pdf/reeusp/v46n2/a29v46n2.pdf
http://www.scielo.br/pdf/reeusp/v46n2/a2...
). Compression, topical, drug or surgical therapy are some of the treatments for wounds. Choosing the best option depends on the evaluation of a multidisciplinary team(1616. Costa I, Pinheiro L, Melo GSM, Torres GV. Protocolo de assistência a pessoas com úlcera venosa na atenção primária: revisão integrativa da literatura. Rev Fundam Care [Internet]. 2013 [citado 2017 dez. 10];9(2):566-74. Disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/4353
http://www.seer.unirio.br/index.php/cuid...
) formed by physicians, nurses, physiotherapists, among others. Compression therapies can be elastic (stockings, single or multilayer bandage), inelastic (Unna boot) or intermittent pneumatic(1717. Nicolosi JT, Altran SC, Barragam JP, Carvalho VF, Isaac C. Terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico. Aquichán. 2015;15(2):285-95.).

The Unna boot is a form of therapy with compression of 18-24 mmHg. Its composition can vary from the traditional form that requires previous thermal heating, and the industrial, ready-to-use form, which is the most used, slightly divergent in components and contains 10% of zinc oxide, gum acacia, glycerol, castor oil and deionized water(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.). This technique was developed in 1896 by the German dermatologist Paul Gerson Unna(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.). The Unna boot should be changed between every three to seven days, and the procedure is performed by the nursing or physician, depending on exudate and edema(2020. Center Disease Control and Prevention. Guidelines for Preventing Opportunistic lnfections among Hematopoietic Stem Cell Transplant Recipients: recommendations of the CDC, the Infectious Diseases Society of America, and the American Society of Blood and Marrow Transplantation. Atlanta; 2010.). If the therapy is not applied correctly, it becomes ineffective for venous hypertension control, increases the recurrence rates of ulcers and implies complications. The Unna boot is wrapped around the leg, calf and foot. During rest and muscle contraction, there is compression, as it acts on macrocirculation by increasing venous return, and on tissue pressure by favoring the reabsorption of edema and the return of fluids located in interstitial spaces in the interior of the vascular and lymphatic system, which promotes healing of the injury and prevents inflammation(2121. Wounds International. Principles of compression in venous disease: a practitioner's guide to treatment and prevention of venous leg ulcers. London; 2013.).

This treatment has shown good results. The expectation of cure in three months is 40% to 60% and, from six months to one year, it can reach 70%(2222. Phillips TJ, Machado F, Trout R, Porter J, Olin J, Falanga V. Prognostic indicators in venous ulcers. J Am Acad Dermatol. 2000;43(4):627-30.). Among the therapy benefits, are protection against trauma and minimal interference in daily activities. However, it is contraindicated in cases of mixed ulcers, swelling, erythema(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.), bedridden, wheelchairs and inflammatory process in the injury(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.).

Wound monitoring should be individualized and dynamic. It requires an intense knowledge and commitment from professionals(99. Brito CKD, Cardoso NI, Victor JF, Feitoza SMS, Silva MG, Amaral HEG. Úlcera venosa: avaliação clinica, orientações e cuidados com o curativo. Rev Rene. 2013;14(3):470-80.), since the injury responds differently to each type of product associated with compression. After the end of the ulcer treatment with the Unna boot, the use of compression stockings in order to avoid relapses is indicated(2323. Borges EL, Ferraz AF, Carvalho DV, Matos SS, Lima VLAN. Prevenção de recidiva de úlcera varicosa: um estudo de coorte. Acta Paul Enferm [Internet]. 2016 [citado 2017 set. 21];29(1):9-16. Disponível em: http://www.scielo.br/pdf/ape/v29n1/1982-0194-ape-29-01-0009.pdf
http://www.scielo.br/pdf/ape/v29n1/1982-...
).

The aim of this study was to identify, characterize, describe and analyze the literature related to the types of compression therapies in venous injury by emphasizing the use of the Unna boot and its impact on health practice and care in order to reconstruct the current knowledge on the subject. By considering the importance of expanding knowledge and reflection on the subject, it was necessary to review the scientific production based on the integrative review in order to examine the approached theme, assistance protocols, professional aspects, survey of the biopsychosocial characteristics involved and comparison between therapies.

METHOD

The present study was conducted based on an integrative review of the literature in order to list the bibliography with different methodological approaches on compression therapies in venous injury focused on use of the Unna boot. A methodological guideline of six segments was followed in order to perform the review, as follows: 1. identification of the theme, 2. selection of the hypothesis or research question, 3. establishment of criteria for inclusion and exclusion of studies, sampling and search in the literature, 4. definition of the information to be extracted from the selected studies and categorization of studies; 5. evaluation of included studies; 6. interpretation of results, presentation of the review and synthesis of knowledge(2424. Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Contexto Enferm. 2008;17(4):758-64.).

The topic chosen and the question to be answered addressed the scientific knowledge produced, the applications of compression therapy in venous injury, especially the use of the Unna boot. In health publications, the available evidence in the literature was investigated, and the main aspects related to use of the Unna boot were discussed, compared to other techniques applied in venous ulcer with emphasis on the boot effectiveness reduction of edema and healing. The justification for the limitation of the search period of studies between 2012 and 2016 is that it provided a current and objective character to the study.

The data collection period was the first half of 2017, and the aim was to select publications for analysis and subsequent study. The following databases were used: Virtual Health Library (VHL), Latin American and Caribbean Literature in Health Sciences (LILACS), Brazilian Nursing Database (BDENF), Scientific Electronic Library Online (SciELO), US National Library of Medicine National Institutes of Health (PubMed) and Medical Literature Analysis and Retrieval System Online (MEDLINE). As shown in Chart 1, the descriptors were crossed in each database. In PubMed, the ‘MeSH Terms’ descriptors were maintained in English only, since the included articles are in this language.

Chart 1
Crossings of terms according to the selected databases in English, Portuguese and Spanish.

The descriptors (boot, unna, varicose, ulcer, therapy, compression, venous, leg, bota, úlcera, varicosa, terapia, compressiva, venosa, compresiva and la pierna) and keywords (unna, boot and bota) were combined in a variety of ways in order to guarantee diversity in the search.

Inclusion criteria were scientific articles available in full in the main scientific research sites on the internet with free access, available in Portuguese, Spanish or English, and that addressed the use of compression therapy with focus especially on use of the Unna boot as a descriptor of the area of interest.

According to criteria, among the highlighted works, those that did not respond to the objective of this review were excluded, as well as book chapters, manuals, literature reviews, editorials, reviews, course papers, theses, dissertations or papers presented at scientific events. A limit of the year of publication of articles (between 2012 and 2016) was established. The selection, reading and evaluation of studies was performed thoroughly, first through titles and abstracts and, finally, in full in order to group the studies related to compression therapy, especially to the Unna boot, that met the mentioned inclusion criteria.

The method used to group the data was a spreadsheet containing information about authors and year of publication of the study; database; place of development; language of publication; aims; methodology; results and conclusions of studies.

The final synthesis was presented descriptively by considering the objectives, results and conclusions obtained in each study. These data were classified and recorded by similarity and ordered in thematic categories. The process of identification, selection and inclusion of the primary studies was performed in three steps, as shown in Figure 1. In the first step, were excluded 188 duplicate articles out of the 1,814. In the second step, were selected 193 articles after reading 1,626 titles and abstracts. The third step included careful reading of 49 articles in full, out of which 27 were eliminated because they did not answer the guiding question of the present review. Therefore, 22 relevant articles were included in this final sample.

Figure 1
Flowchart of identification, screening and inclusion of integrative review studies.

RESULTS

For the development of the integrative review the methodological course of six steps was followed. The final sample had 22 articles, as shown in Chart 2, encompassing 15,931 individuals aged 35 years or over. Eleven studies (50%) included participants from South America(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):41-9.1919. 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.,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;27:466-71.3333. 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.), four (18%) from North America(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):8-13.3737. 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.), four (18%) from Europe(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):34-43.4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.), one (4%) from Australasia(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.), one from Asia(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.) and another (4%) from Oceania(4444. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.). The longest follow-up time was 13 years(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.), and the lowest time was 28 days(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.). Only one article did not mention the defined period(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.).

Chart 2
Summary of the characteristics of studies included in the review according to authors, article title, year of publication, social network studied, main results and recommendations and conclusions.

The articles were published in international journals, and predominantly in English, only four were in Portuguese(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;27:466-71.2626. 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.,3232. Lima MSFS, Carvalho ESS, Gomes WS. Diagnósticos de enfermagem em mulheres usuárias de bota de Unna. Rev Baiana Enferm; 2014;28(2):156-67.3333. 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.), and one in Spanish(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.). In all articles there was always an author from nursing departments or institutions. There were several study designs divided as follows; one of each (5%): longitudinal(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.), comparative analysis(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.), qualitative analysis(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.), case-control(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.), descriptive(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.) and observational(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.); two of each (9%): cross-sectional(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.,4444. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.) and retrospective(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.,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.); three of each (14%): cohort(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.,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.,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.) and case reports(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.,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.,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.); and eight (36%) clinical trials(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.,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.,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):655-61.3939. 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.,4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.4343. 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.), among which four (18%) were controlled trials comparing two or more types of compression therapies, and taking into consideration the rate of reduction or healing of the injury as an evaluation parameter, as described in Table 1.

Table 1
Summary of comparative studies included in the review according to authors, year of publication, amount and total of the sample, type of compression therapy compared and results.

With reference to the target population, samples included subjects affected or not by comorbidities (smoking, obesity, diabetes, hypertension). The female representation was 55% and the male was 45% of the total number of participants. In this review, the mean age of the sample was 35-78 years, and the highlight was the age above 60 years.

Among some reports on the limitation of studies, the following stood out: small number of participants(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.,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.), short duration, absence of blind method, absence of placebo(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):34-43.3939. 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.), impossibility of access to inactive medical records (deaths and absence of consultations in the last two years)(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.) and participants’ withdrawal(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.). In relation to reduction of the wound area, the lowest rate was 5%(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.) and the highest was 96%(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.).

In this review, seven types of compression therapies were mentioned, namely: the Unna boot (14 studies; 63%)(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.,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;27:466-71.3535. 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.,4444. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.); single-layer bandage (five studies; 23%)(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):637-44.2727. 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.,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.,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.,4444. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.); two-layer bandage (two studies; 9%)(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.,4444. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.); three-layer bandage (two studies; 9%)(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 7:40-1.4444. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.); four-layer bandage (one study; 5%)(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.); use of stocking (five studies; 23%)(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.,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;27:466-71.3030. 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.,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.,4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.,4444. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.); intermittent pneumatic (two studies; 9%)(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):34-43.3939. 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.) latex free tubular bandage (one study; 5%)(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.). In 11 studies (50%)(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.,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.,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):571-7.3131. 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.,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;12:346-54.3939. 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.,4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.4343. 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.), some of these therapies were compared. The Unna boot was studied in 13 (60%) articles, of which 11 were conducted in Brazil(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):41-9.1919. 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.,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.,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.,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):414-22.3333. 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.), and the others in the USA(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.), Poland(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.) and United Kingdom(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.); in five of these studies (23%), the Unna boot was compared to another therapy(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.,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):571-7.3131. 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.,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.,4444. Zarchi Kian, Jemec GBE. Delivery of compression therapy for venous leg ulcers. JAMA Dermatol. 2014;150(7):730-6.), and in eight (36%)(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):41-9.1919. 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.,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;27:466-71.2727. 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.,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.,3232. Lima MSFS, Carvalho ESS, Gomes WS. Diagnósticos de enfermagem em mulheres usuárias de bota de Unna. Rev Baiana Enferm; 2014;28(2):156-67.3333. 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.,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.) only the boot was studied.

The Unna boot was tested with the simple dressing as control, which is not compressive, but composed of gauze, band and 0.9% physiological solution(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.). However, another five (23%) researchers described the results of using the Unna boot(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.,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.,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.,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.,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.) by adopting various forms of analysis in order to prove its efficiency for healing venous injuries. In a qualitative research(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.), tests with compression therapy were not performed, and biopsychosocial and spiritual aspects involved in the person using the Unna boot were addressed. When the Unna boot was compared to other therapies, it demonstrated a shorter healing time than the single and two-layer elastic bandage(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.,4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.).

Among the results and benefits of using compression therapy in venous ulcers, eight articles (36%) indicated the effectiveness of the Unna boot in control of edema, reduction of wound area and wound healing, and for improving patients’ quality of life(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):41-9.1919. 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.,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.,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.,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.,3232. Lima MSFS, Carvalho ESS, Gomes WS. Diagnósticos de enfermagem em mulheres usuárias de bota de Unna. Rev Baiana Enferm; 2014;28(2):156-67.3434. 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.). In two studies (9%), the low rate of indication of this therapy by professionals was criticized(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.,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.). In four articles (18%), the authors emphasized the efficiency of the multilayer bandage(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.,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.,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):21-7.4343. 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.); in two (9%) of the trials, one author argued for the efficiency of intermittent pneumatic compression(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.,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.), besides mentioning the benefits of the single-layer bandage in two literatures (9%)(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):22-30.4040. 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.). In other four articles (18%), the two-layer bandage was considered effective(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.,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):22-30.4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.), and in one (5%) the elastic stocking was considered effective(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.). One study presented no evidence(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.).

DISCUSSION

Elastic or inelastic compression therapy is the most recommended method for treating venous ulcers(5050. European Wound Management Association. Position document: understanding compression therapy. London: MEP; 2003.). As reinforced by authors of the Cochrane database in 2012, there was an increase in healing rates compared to no compression(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.). Since ancient times(5151. Galanaud JP, Laroche JP, Righini M. The history and historical treatments of deep vein thrombosis. J Thromb Haemost. 2013;11(3):402-11.), and after the year 1628, when a physician related venous stasis with external pressure, elastic stockings of the most varied components were produced, such as resin bandages, natural fibers, cellulose (silk, cotton, coconut) and chemicals (acrylic, nylon, polyester)(5252. Conferência Nacional de Consenso Sobre Ulceras das Extremidades Inferiores. Úlcera de etiologia venosa. Espana; CONUEI; 2009.). This technology has undergone constant advances by promoting several benefits, such as venous return aid(5353. Koksal C, Bozkurt AK. Combination of hydrocolloid dressing and medical compression stockings versus Unna's boot for the treatment of venous leg ulcers. Swiss Med Wkly. 2003;133(25-26):364-8.), the reduction of pain and leg circumference, the influence in exudation of lymphatic flow fluids, and the attenuation of venous hypertension(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.). Several studies in the area pointed the increased use of compression therapy over time(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.).

In this study, there was homogeneity in relation to the sex variable in the sample, with 55% of women, as described in other literatures(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.,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.,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.,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):1-9.3434. 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.,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.,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.), but in opposition to another study, in which there was 67% prevalence of men(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.). This difference can be explained by women's predisposition to varicose veins associated with age and body mass index (BMI), as well as hormonal changes(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.,5353. Koksal C, Bozkurt AK. Combination of hydrocolloid dressing and medical compression stockings versus Unna's boot for the treatment of venous leg ulcers. Swiss Med Wkly. 2003;133(25-26):364-8.). The increase in life expectancy increases the number of elderly patients(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.) who are prone to ulcers because of malfunctioning of the vascular system. Regarding the predominant age of this review, the results were similar to those found in the literature(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):41-9.1919. 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.,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.,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):558-61.2828. 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.,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):34-43.3939. 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.,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):21-7.4343. 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.,5454. Frade MAC, Cursi IB, Andrade FF, Soares SC, Ribeiro WS, Santos SV et al. Úlcera de perna: um estudo de casos em Juiz de Fora-MG (Brasil) e região. Anais Bras Dermatol. 2005;80(1):41-6.).

Brazilian and international guidelines(5555. Clinical Resource Efficiency Support Team. Guidelines for the assessment and management of leg ulceration. Belfast: CREST; 1998.) recommend the adoption of the Doppler ultrasound examination for the diagnosis of leg ulcers. Although the equipment cost is viable, this evidence has rarely been documented in the literature, and in Europe, there were reports in agreement with this fact in a developed country like the United Kingdom(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.). This reality may also be that of other localities. The treatment of venous ulcers requires long term follow-up, results in physical, functional, emotional and financial problems for patients(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.), in addition to generating costs for health reserves and causing obvious socioeconomic impacts.

The main anatomical location described for ulcers was the malleolar region, which is in line with the literature(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.). The duration of ulcers’ evolution (in months) ranged from a minimum of two to a maximum of 792 months. A comparison of the Unna boot with a two-layer bandage(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.) indicated a minimum of four and a maximum of 120 months, and the duration of ulcer was associated with age(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.). The healing time of injuries was 94 months, on average(5454. Frade MAC, Cursi IB, Andrade FF, Soares SC, Ribeiro WS, Santos SV et al. Úlcera de perna: um estudo de casos em Juiz de Fora-MG (Brasil) e região. Anais Bras Dermatol. 2005;80(1):41-6.).

“The choice of dressing type in cutaneous wounds depends on assessment of patients and the wound appearance. There are many coverage options available in the market”. In this review, studies that tested the application of the different therapies used worldwide were found. In each region, there is a tendency to use a certain technique, and this choice is based on the cost-benefit and availability of the product. There was a strong trend related to the socioeconomic aspects of a territory(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.).

According to this review, the type of treatment varied by region. In two studies conducted in Poland(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):34-43.3939. 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.), prevailed the use of multilayer, double or single-layer bandage, stockings and pneumatic compression, which acts in deep veins by promoting prophylaxis of thrombosis and influencing fibrinolysis, tissue oxygenation, edema and venous return(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.). There is no possibility of implementing intermittent therapy in economically disadvantaged places. In addition to the high cost of equipment, the absence of electric energy makes it unfeasible. In one study, there was more ulcer recurrence among those who used bandage rather than stockings hence its use on an enlarged scale would provide substantial resource savings(4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.). In a study conducted in Hong Kong(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.), the four-layer and two-layer bandage were compared to non-compression bandage. In another study in Australia(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.), the four and two-layer therapy were compared. It was not possible to conclude that the four-layer bandage was more effective than single-layer bandage, but compression therapies indicated better healing results than no compression. Such results were associated with faster responses in injury reduction(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.,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.). Currently, multilayer bandage is considered the gold standard for the treatment of venous ulcers because it reduces healing time(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.) compared to other therapies, but it is not available in the Brazilian Health System and is high costly(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.).

In articles analyzed in this review, the authors showed the use of two-layer bandage in the United Kingdom(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):e58948.4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.), the use of two-layer and multilayer bandage, and the Unna boot in the United States(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.,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.,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.), and two and four-layer bandage in Canada(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.). In New Zealand, attention was drawn to a study in which nurses applied compression therapies, and there were technical failures of the professionals.

According to the analysis, there was a significant improvement in quality of life, pain and self-esteem after the use of the Unna boot and healing of injuries by reaching the 84% rate of wound healing(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.). Several authors(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):41-9.1919. 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.,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.,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.,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.,3232. Lima MSFS, Carvalho ESS, Gomes WS. Diagnósticos de enfermagem em mulheres usuárias de bota de Unna. Rev Baiana Enferm; 2014;28(2):156-67.3434. 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.) advocate the use of the Unna boot for its effective healing properties and lower costs. Generally, patients who adapt to the boot technique achieve high levels of satisfaction related to minimal wound care, develop fast granulation, considerable levels of comfort(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.), besides the excellent aesthetic result(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.).

As described in Table 1, the five controlled trials according to criteria defined in the methodology were tested and compared regarding the various compression techniques, among which the pneumatic, single and two-layer stockings, double and multilayer bandages, elastic bandage, Unna boot and no compression. Among them, the multilayer bandage and pneumatic bandage add more technology and cost, and the Unna boot, in turn, when compared to these, is inferior in healing time. However, when comparing the Unna boot to the single and two-layer elastic bandage, it was more efficient. The Unna boot was not widely used outside Brazil, which shows that other countries tend to use other techniques. As a compression therapy, the Unna boot was superior when compared to the single and two-layer bandage(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.,4141. Adderley U, Stubbs N. Stockings or bandages for leg-ulcer compression? Nurs Times. 2014;110(15):19-20.).

In this review, few studies comparing techniques were found. There are many related variables, there is no homogeneity of tests of the Unna boot in the world, and they are focused on Latin America, while the bandages and stockings are focused on Europe and USA. Few studies in Brazil were controlled, there was predominance of case reports, longitudinal, descriptive, cohort or qualitative trials. This may suggest that economic factors are decisive in compressive venous injury therapy. Controlled studies are often costly, so they may have been less frequent in developing countries, such as Brazil, where challenges regarding investment for research are faced.

The bandaging technique requires professional skill because “the intensity of the external compression applied to the lower limbs should decrease from the ankle to the knee in order to reverse the effect produced by prolonged orthostatism, that is, the increase of intravascular hydrostatic pressure”(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.). However, if the technique is performed erroneously, it can either strangle or leave the bandage loose, which may compromise the effectiveness of the treatment.

Bandages act as a ‘physical barrier’ by protecting and isolating the injury from possible traumas. In relation to pain, as the Unna boot does not have elastomeric fiber, it does not shape any changes in leg volume, thus exerting pressure on the calf musculature, which can generate a possible discomfort during walking and rest(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.).

Patient adherence to treatment is important to prevent relapse(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.,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.). The high number of relapses may be related to non-adherence to preventive measures, such as the use of compression stockings after healing of ulcers, lack of post-healing monitoring with angiologists, among other factors(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.,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.). Given the socioeconomic and territorial diversity of Brazil, in the Midwest region of the country, it was identified that 67% of patients had access to the mentioned specialist, unlike another author, who indicated the access of only 25.7% of patients in the Northeast region(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.).

“In the international scenario, there is a trend of existing trained professionals for application of compression therapy and systematic follow-up, without necessarily restricting its indication by the medical professional, but, the evaluation should be performed by a vascular specialist in cases of people with altered ankle-arm index (less than 0.8), diabetes and lack of response in reducing the size of the injury after one month of compression therapy”(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.). In Brazil, only the physician, usually the vascular specialist, is able to indicate the use of the Unna boot. The application and removal according to medical prescription is performed by the trained nurse or nursing technician, and the follow-up is under responsibility of the nurse together with the physician(5656. Rio Grande do Sul (Estado). Lei n. 5.905/73, de 30 de junho de 2016. Dispõe sobre a competência profissional para realização de procedimento de bota de Unna. Porto Alegre: Conselho Regional de Enfermagem do Rio Grande do Sul, Câmara Técnica de Atenção Básica e Saúde e Urgência e Emergência; 2016.). After analysis of this review, and in agreement with the studies selected, the recommendation is that the “nurse be aware of the signs of new injuries” and skin changes during the nursing consultation(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.,5656. Rio Grande do Sul (Estado). Lei n. 5.905/73, de 30 de junho de 2016. Dispõe sobre a competência profissional para realização de procedimento de bota de Unna. Porto Alegre: Conselho Regional de Enfermagem do Rio Grande do Sul, Câmara Técnica de Atenção Básica e Saúde e Urgência e Emergência; 2016.). The interaction of the trained multidisciplinary team associated to the cooperation of patients is essential for treatment(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.,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.).

CONCLUSION

The authors of the studied literature discussed the main aspects related to the use of compression therapies, in particular those of the Unna boot that was emphasized by its effectiveness in reducing edema and healing compared to other techniques applied to venous ulcer. From the analysis found in the journals, it was observed the improvement of scientific knowledge about compression therapies with presentation of their benefits in general. However, these techniques must be permanently studied, disseminated and compared with the objective of constant advances in the treatment of patients with venous ulcer. Still, the efficacy of such techniques is closely related to professionals’ training, multidisciplinary involvement, cooperation and patient adherence.

Although other compression techniques may prove to be more efficient than the Unna boot by adding more technology, the boot still stands out as a traditional low-cost dressing that reduces venous hypertension and edema, and favors the treatment of venous ulcers. The multilayer bandage is a gold standard technique in developed countries and has been widely used, but the Unna boot has also been used as an option for treatment of venous injury. This review showed that the Unna boot may not be the best choice because it requires a higher healing time compared to the multilayer bandage, but it meets the expectation with a high rate of treatment efficiency, even if compared to the simple dressing, and single and two-layer bandage.

The information obtained in the scientific literature has highlighted the effectiveness of the Unna boot by showing that for its efficiency, the therapy requires wide dissemination in scientific circles, new research and continuous and ongoing training of nursing professionals and physicians in order to increase confidence in its indication and handling. More assertive investments in health are needed both in public and private sectors, given the challenges faced in vascular injuries care. Success in the treatment of venous ulcers is multifactorial, depends on correct indication, professional evaluation, follow-up with wound measurement, association between therapies/products, rest, correct elevation of limbs, no manipulation of the patient, adhesion and correct wound cleaning. In terms of cost-benefit, the Unna boot is a great choice as a form of compression therapy, because it is affordable, available in SUS and requires low technology. Its benefits and efficiency overlap the possible discomforts.

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Publication Dates

  • Publication in this collection
    29 Nov 2018
  • Date of issue
    2018

History

  • Received
    13 Dec 2017
  • Accepted
    07 June 2018
Universidade de São Paulo, Escola de Enfermagem Av. Dr. Enéas de Carvalho Aguiar, 419 , 05403-000 São Paulo - SP/ Brasil, Tel./Fax: (55 11) 3061-7553, - São Paulo - SP - Brazil
E-mail: reeusp@usp.br