A prospective, randomized trial of Unna's boot versus Duoderm CGF hydroactive dressing plus compression in the management of venous leg ulcers

Abstract

In a recent issue of the Journal, Cordts et al.1Cordts PR Hanrahan LM Rodriguez AA Woodson J LaMorte WW Menzoian JO. A prospective, randomized trial of Unna's boot versus Duoderm CGF hydroactive dressing plus compression in the management of venous leg ulcers.J Vasc Surg. 1992; 15: 480-486Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar clearly demonstrated the benefit of compression in the treatment of venous stasis ulcers. In their study 8 of 16 ulcers (50%) treated by Duoderm and a Coban wrap healed completely versus 6 of 14 (43%) treated by Unna's boot. Healing was also faster in the Duoderm treated group at least at 4 weeks. I have described similar but even more notable improved healing with patients using the Jobst UlcerCare (Jobst Institute, Inc., Toledo, Ohio).2Samson RH. Compression stockings and non-continuous use of polyurethane foam dressings for the treatment of venous ulceration. J Dermatol Surg Oncol (In press.)Google Scholar This treatment option uses a hydrophillic sponge dressing and a combination of two compression garments: an inner liner stocking worn night and day and providing 10 mm Hg pressure, and an outer, zippered stocking adding a further 30 mm Hg pressure during waking hours. In a study of 25 lower extremity ulcers in patients with chronic deep venous insufficiency confirmed by duplex scanning, 21 ulcers (84%) healed after 2 to 30 weeks of treatment, (mean 8.3, median 5 weeks).2Samson RH. Compression stockings and non-continuous use of polyurethane foam dressings for the treatment of venous ulceration. J Dermatol Surg Oncol (In press.)Google Scholar The remaining four ulcers healed by more than 50% of their surface square area within 9 weeks of treatment. Of special interest is that 15 ulcers had already failed attempts at healing with Unna's boots supplemented by elastic bandage wraps. Thirteen of these had also not improved with Duoderm and elastic bandage wraps. Maceration of the surrounding skin, sometimes seen with Duoderm, did not occur with the UlcerCare product. Rubin et al.,3Rubin JR Alexander J Plecha EJ Marman C. Unna's boot versus polyurethane foam dressings in the treatment of venous ulceration; randomized prospective study.Arch Surg. 1991; 125: 489-490Crossref Scopus (66) Google Scholar in a study of dressings similar to Duoderm, found that 6 of 19 patients had to give up therapy when maceration resulted in worsening of the ulcer. The superior results with the Jobst UlcerCare may be related to the ability to cleanse the ulcer on a regular basis, a feature not practical with Duoderm. Furthermore, well-constructed surgical stockings may apply better gradient pressure than bandage wraps. The hydrophillic foam pad also results in pressure being applied directly to the ulcer base, another feature not feasible with Duoderm. In conclusion, it is apparent that good compression is probably the key factor in healing of stasis ulcers. Small ulcers that do not form a large exudate will probably heal rapidly no matter what local dressing is applied under the compression garment or wrap. In such cases, Duoderm (Convatec, Inc., Princeton, N.J.) or other equivalent polyurethane dressings (e.g., Intrasite; Smith and Nephew United, Inc., Largo, Fla.) or the hydrophillic sponges (e.g., Allevyn; Smith and Nephew United, Inc.) are interchangeable. However, larger exudative ulcers may benefit from frequent dressing changes and improved local hygiene, a feature not offered by occlusive dressings such as Duoderm. Irrespective, both reported methods appear to be better than simple Unna's boots. Patient compliance and comfort are also enhanced by the former dressings. I am hopeful that the old workhorse, the Unna's boot, will finally be put out to pasture!