Effect of Unna's boot on venous ulcer healing: a systematic review and meta-analysis

Cordova, Fernanda Peixoto; Furhmann, Ana Claudia; do Carmo, Andreia Cristina Feitosa; Vales, Eduardo Nunes; Terra, Diego Henrique; da Silva, Bárbara Uuritz; Machado, Diani de Oliveira; Lucena, Amália de Fátima; Paskulin, Lisiane Manganelli Girardi

doi:10.1590/1980-220X-REEUSP-2023-0397en

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Revista da Escola de Enfermagem da USP

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REVIEW • Rev. esc. enferm. USP 58 • 2024 • https://doi.org/10.1590/1980-220X-REEUSP-2023-0397en copy

Effect of Unna's boot on venous ulcer healing: a systematic review and meta-analysis

Efecto de la bota de Unna en la cicatrización de úlceras venosas: revisión sistemática y metanálisis

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objective:

To analyze the effect of Unna’s Boot on the healing of venous ulcers compared to other therapies.

Methods:

Systematic Review carried out in the databases Scopus, Embase, Cochrane Library, Web of Science, PubMed, Cumulative Index of Nursing and Allied Health Literature, Latin American and Caribbean Literature in Health Sciences, and grey literature. Population – adult patients with venous ulcers; Intervention- Unna’s Boot (UB); Control – other compression therapies (CT); Outcome- healing; Designs- randomized clinical trial, cohort study, and case control, published from 2001 to 2024. The effect of the intervention, risk of bias, and quality of evidence were evaluated. Registered with PROSPERO (CRD42021290077).

Results:

A total of 39 studies were included, with 5.151 patients. The majority (71.8%) were randomized controlled trials (RCT). UB was used as intervention/control in eight studies. When comparing CTs, only 1 study with UB showed a superior effect (p < .001) in healing, compared with high compression elastic bandage. In the quality of evidence analysis, 27 studies were assessed as having a high risk of bias.

Conclusion:

No superiority of UB was found in the healing of venous ulcers when compared to other CTs.

DESCRIPTORS
Varicose Ulcer; Compression Bandages; Stockings, Compression; Systematic Review; Meta-Analysis

Variables	N	%
Year
2002	1	2.5
2003	2	5.1
2004	5	12.8
2005	1	2.5
2007	1	2.5
2008	2	5.1
2010	3	7.6
2011	2	5.1
2012	3	7.6
2013	2	5.1
2014	5	12.8
2015	3	7.6
2019	2	5.1
2020	2	5.1
2021	1	2.5
2022	2	5.1
2023	2	5.1
Country
UK	8	20.5
Brazil	7	17.9
Italy	4	10.2
Germany	3	7.6
France	3	7.6
Serbia	3	7.6
Australia	2	5.1
United States of America	2	5.1
Poland	2	5.1
Argentina	1	2.5
Canada	1	2.5
China	1	2.5
Spain	1	2.5
Turkey	1	2.5
Design of study
RCT	14	35.8
Multicenter RCT	12	30.8
Pragmatic multicenter RCT	1	2.6
Cross-over multicenter RCT	1	2.6
Cohort	8	20.5
Retrospective cohort	2	5.1
Case-control	1	2.6
Sex (28 studies)	2,247	54.3
Female	1,891	45.7
Male
Age (mean/SD) (28 studies)
68.6 years (± 6.0)
Intervention
Unna's Boot	8	20-20.5
4-layers bandage	7	17.9
Elastic stockings	6	15.3
2-layers bandage	5	12.8
High compression bandage	3	7.7
Inelastic stockings	3	7.7
Control
4-layers bandage	9	23.1
Short-stretch bandage	9	23.1
2-layers bandage	8	20.5
Bandage without compression	5	12.8
rating	2	5.1
Unna's Boot
Follow-up Time (Median/IQ)
Weeks	12	12-24

Author year	Study design	Intervention group (IG) (n)	Control group (CG) (n)	Follow-up (weeks)	Summary of main results
Meyer et al., 2002(²⁴24. Meyer FJ, Burnand KG, Lagattolla NR, Eastham D. Randomized clinical trial comparing the efficacy of two bandaging regimens in the treatment of venous leg ulcers. Br J Surg. 2002;89(1):40–4. doi: http://doi.org/10.1046/j.0007-1323.2001.01936.x. PubMed PMID: 11851661. https://doi.org/10.1046/j.0007-1323.2001... )	Cohort	High compression elastic bandage (n = 57)	Short-stretch bandage (n = 55)	26	Healing ratep = .623 IG: 58% (n = 33) CG: 62% (n = 34) *Healing time^ weeks;* IG: 10 (95% CI 8–12) CG: 11 (95% CI 9–13)
Meyer et al., 2003(²⁵25. Meyer FJ, McGuinness CL, Lagattolla NR, Eastham D, Burnand KG. Randomized clinical trial of three-layer paste and four-layer bandages for venous leg ulcers. Br J Surg. 2003;90(8):934–40. doi: http://doi.org/10.1002/bjs.4173. PubMed PMID: 12905544. https://doi.org/10.1002/bjs.4173... )	Cohort	3-layers (n = 64)	4-layers (n = 69)	56	Healing rate p = .031 IG: 80% (n = 51) CG: 65% (n = 45) *Healing time^ weeks; P = .040* IG: 12 (95% CI 10–15) CG: 16 (95% CI 13–21)
Ukat et al., 2003(²⁶26. Ukat A, Konig M, Vanscheidt W, Munter KC. Short-stretch versus multilayer compression for venous leg ulcers: a comparison of healing rates. J Wound Care. 2003;12(4):139–43. doi: http://doi.org/10.12968/jowc.2003.12.4.26490. PubMed PMID: 12715486. https://doi.org/10.12968/jowc.2003.12.4.... )	RCT	4-layers (n = 44)	Short-stretch bandage (n = 45)	12	Healing rate IG: 30% (n = 13) CG: 22% (n = 10) *Healing time^ weeks; p = .03* OR 2.9 (95% CI 1.1–7.5)
Franks et al., 2004(²⁷27. Franks PJ, Moody M, Moffatt CJ, Martin R, Blewett R, Seymour E, et al. Randomized trial of cohesive short-stretch versus four-layer bandaging in the management of venous ulceration. Wound Repair Regen. 2004;12(2):157–62. doi: http://doi.org/10.1111/j.1067-1927.2004.012206.x. PubMed PMID: 15086766. https://doi.org/10.1111/j.1067-1927.2004... )	RCT^♦ ♦multicenter RCT;	4-layers (n = 74)	2 cohesive layers (n = 82)	24	Healing ratep = .79 IG: 85% (n = 63) CG: 83% (n = 68)
Iglesias et al., 2004(²⁸28. Iglesias C, Nelson EA, Cullum NA, Torgerson DJ, Ven US. Team. VenUS I: a randomised controlled trial of two types of bandage for treating venous leg ulcers. Health Technol Assess. 2004;8(29):1–105. http://doi.org/10.3310/hta8290. PMid:15248939. https://doi.org/10.3310/hta8290... )	RCT^♦ ♦multicenter RCT;	4-layers (n = 195)	Short-stretch bandage (n = 192)	24	Healing rate p = .005 IG: 68% (n = 133) CG: 55% (n = 106) *Healing time^ weeks;* p = .12 IG: 92 (95% CI 71–113) CG: 126 (95% CI 95–157)
Junger et al., 2004a(²⁹29. Junger M, Partsch H, Ramelet AA, Zucarelli F. Efficacy of a ready-made tubular compression device versus short-stretch compression bandages in the treatment of venous leg ulcers. Wounds. 2004a [cited 2024 Jan 9];16(10):313–20. Available from: https://www.hmpgloballearningnetwork.com/site/wounds/article/3232 https://www.hmpgloballearningnetwork.com... )	RCT^♦ ♦multicenter RCT;	Elastic stockings (n = 88)	Short-stretch bandage (n = 90)	12	Healing rate IG: 58% (n = 51) CG: 57% (n = 51) *Healing time^ weeks;* p = .80 IG:43 (±18.3) CG: 43.6 (±18.3) UV area difference^# #% reduction; IG: 67.6% CG: 59%
Junger et al., 2004b(³⁰30. Jünguer M, Partsch H, Ramelet AA, Zuccarelli F. Efficacy of ready-made tubular compression device versus short-stretch compression bandages in the treatment of venous leg ulcers. Wounds. 2004b [cited 2024 Jan 9];16(10):313–20. Available from: https://www.hmpgloballearningnetwork.com/site/wounds/article/3232 https://www.hmpgloballearningnetwork.com... )	RCT^♦ ♦multicenter RCT;	Elastic stockings (n = 61)	2-layers short-stretch bandage (n = 60)	12	Healing rate p = .0129 IG: 47.5% (n = 29) CG: 31.7% (n = 19) Healing time^ days; p = .0297 IG: 61 (±26) CG: 68 (±25)
Polignano et al., 2004(³¹31. Polignano R, Bonadeo P, Gasbarro S, Allegra C. A randomised controlled study of four-layer compression versus Unna’s Boot for venous ulcers. J Wound Care. 2004;13(1):21–4. doi: http://doi.org/10.12968/jowc.2004.13.1.26563. PubMed PMID: 14969023. https://doi.org/10.12968/jowc.2004.13.1.... )	RCT^♦ ♦multicenter RCT;	4-layers (n = 39)	Unna’s Boot (n = 29)	24	Healing ratep = .42 IG: 74% (n = 29) CG: 66% (n = 19) *Healing time^ weeks;* p = .13 IG: 51 (95% CI 7–175) CG: 49 (95% CI 7–168) UV area difference^# #% reduction; p = .30 IG: 100% (95% CI –283.3–100) CG: 100% (95% CI –489.3–100)
Blecken et al., 2005(³²32. Blecken SR, Villavicencio JL, Kao TC. Comparison of elastic versus nonelastic compression in bilateral venous ulcers: a randomized trial. J Vasc Surg. 2005;42(6):1150–5. doi: http://doi.org/10.1016/j.jvs.2005.08.015. PubMed PMID: 16376207. https://doi.org/10.1016/j.jvs.2005.08.01... )	RCT	Inelastic stockings (n = 12)	4-layers (n = 12)	12	Healing rate p = .0173 IG: HR 0.56 CG: HR 1 VU area difference^## ##(cm2/week); p = .0369 IG: 2.93 (±0.6) CG: 2.3 (±0.7)
Millic et al., 2007(³³33. Milic DJ, Zivic SS, Bogdanovic DC, Perisic ZD, Milosevic ZD, Jankovic RJ, et al. A randomized trial of the Tubulcus multilayer bandaging system in the treatment of extensive venous ulcers. J Vasc Surg. 2007;46(4):750–5. doi: http://doi.org/10.1016/j.jvs.2007.04.062. PubMed PMID: 17764879. https://doi.org/10.1016/j.jvs.2007.04.06... )	RCT	3-layers with elastic stockings and medium stretch bandage (n = 75)	2-layers medium-stretch bandage (n = 75)	52	Healing time^ days; p < .001 IG: 133 (28–464) CG: 211 (61–438)
Mariani et al., 2008(³⁴34. Mariani F, Mattaliano V, Mosti G, Gasbarro V. The treatment of venous leg ulcers with a specifically designed compression stocking kit: comparison with bandaging. Phlebologie. 2008;37(4):191–7. doi: http://doi.org/10.1055/s-0037-1622230. https://doi.org/10.1055/s-0037-1622230... )	RCT^♦ ♦multicenter RCT;	Ulcer X Kit (n = 26)	Short-stretch bandage (n = 30)	16	Healing rate p = .011 GI: 96.2% (n = 25) CG: 70% (n = 21)
Moffatt et al., 2008(³⁵35. Moffat CJ, Edwards L, Collier M, Treadwell T, Miller M, Shafer L, et al. A randomized controlled 8-week crossover clinical evaluation of the 3M™ Coban™ 2 Layer Compression System versus Profore™ to evaluate the product performance in patients with venous leg ulcers. Int Wound J. 2008;5(2):267–79. doi: http://doi.org/10.1111/j.1742-481X.2008.00487.x. PubMed PMID: 18494632. https://doi.org/10.1111/j.1742-481X.2008... )	ECR^♦♦ ♦♦multicenter cross-over RCT;	2-layers (n = 39)	4-layers (n = 42)	08	Healing rate before^♦♦ ♦♦multicenter cross-over RCT; p = .30 IG: 15.3% (n = 6) CG: 7.1% (n = 3) UV area difference^♦♦# p = .88 IG: 27.8% CG: 42.2%
Brizzio et al., 2010(³⁶36. Brizzio E, Amsler F, Lun B, Blättler W. Comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers. J Vasc Surg. 2010;51(2):410–6. doi: http://doi.org/10.1016/j.jvs.2009.08.048. PubMed PMID: 19879713. https://doi.org/10.1016/j.jvs.2009.08.04... )	RCT	Elastic stockings (n = 28)	Usual care (n = 27)	26	Healing ratep = .210 IG: 50% (n = 14) CG: 67% (n = 18) Healing time^ days; p = .942 IG: 68 (±40) CG: 69 (±39)
Millic et al., 2010(³⁷37. Millic DJ, Zivic SS, Bogdanovic DC, Jovanovic MM, Jankovic RJ, Milosevic ZD, et al. The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. J Vasc Surg. 2010;51(3):655–61. doi: http://doi.org/10.1016/j.jvs.2009.10.042. PubMed PMID: 20045611. https://doi.org/10.1016/j.jvs.2009.10.04... )	RCT	Class III elastic stockings (n = 42)	2-layers^Δ ΔCG1; (n = 46) 3-layers^ΔΔ ΔΔCG2; (n = 43)	26	Healing rate IG: 25% – GI x GC2 p = .000 CG1: 67% CG2: 74% – CG2 x CG1 p = .0238 *Healing time^ weeks;* p > .05 IG: 12 CG1: 11 CG2: 14
Szewczyk et al., 2010(³⁸38. Szewczyk MT, Jawień A, Cierzniakowska K, Cwajda-Białasik J, Mościcka P. Comparison of the effectiveness of compression stockings and layer compression systems in venous ulceration treatment. Arch Med Sci. 2010;6(5):793–9. doi: http://doi.org/10.5114/aoms.2010.17097. PubMed PMID: 22419941. https://doi.org/10.5114/aoms.2010.17097... )	RCT	Class II elastic stockings (n = 15)	2-layers^Δ ΔCG1; (n = 16) 4-layers^ΔΔ ΔΔCG2; (n = 15)	12	Healing ratep > .05 IG: 53.3% (n = 8) CG1: 62.5% (n = 10) CG2: 60% (n = 9) VU area difference^## ##(cm2/week); p < .001 IG: .44 CG1: .55 CG2: .63
Harisson et al., 2011(³⁹39. Harrison MB, Vandenkerkhof EG, Hopman WM, Graham ID, Carley ME, Nelson EA. The Canadian Bandaging Trial: evidence-informed leg ulcer care and the effectiveness of two compression Technologies. BMC Nurs. 2011;10(1):20.doi: http://doi.org/10.1186/1472-6955-10-20. PubMed PMID: 21995267. https://doi.org/10.1186/1472-6955-10-20... )	RCT^♦ ♦multicenter RCT;	4-layers (n = 215)	Short-stretch bandage (n = 209)	12	Healing time^ days; p = .98 IG: 62 (95% CI 51 – 73) CG: 77 (95% CI 63 – 91)
Mosti et al., 2011(⁴⁰40. Mosti G, Crespi A, Mattaliano V. Comparison between a new, two-component compression system with zinc paste bandages for leg ulcer healing: a prospective, multicenter, randomized, controlled trial monitoring sub-bandage pressures. Wounds. 2011;23(5):126–34. PubMed PMID: 25881359.)	RCT	Unna’s boot (n = 50)	2 cohesive layers (n = 50)	12	Healing time^ days; IG: 49.5 (95% CI 27.7 – 69.7) CG: 48 (95% CI 33 – 63.5)
Lazareth et al., 2012(⁴¹41. Lazareth I, Moffatt C, Dissemond J, Lesne Padieu AS, Truchetet F, Beissert S, et al. Efficacy of two compression systems in the management of VLUs: results of a European RCT. J Wound Care. 2012;21(11):553–65, 556, 558 passim. doi: http://doi.org/10.12968/jowc.2012.21.11.553. PubMed PMID: 23413494. https://doi.org/10.12968/jowc.2012.21.11... )	RCT^♦ ♦multicenter RCT;	2-layers (n = 93)	4-layers (n = 93)	12	Healing rate p = .0165 IG: 44% (n = 41) CG: 39% (n = 36)
Weller et al., 2012(⁴²42. Weller CD, Evans SM, Staples MP, Aldons P, McNeil JJ. Randomized clinical trial of three-layer tubular bandaging system for venous leg ulcers. Wound Repair Regen. 2012;20(6):822–9. doi: http://doi.org/10.1111/j.1524-475X.2012.00839.x. PubMed PMID: 23061541. https://doi.org/10.1111/j.1524-475X.2012... )	RCT^♦ ♦multicenter RCT;	3-layers (n = 23)	Short-stretch bandage (n = 22)	12	Healing ratep = .056 IG: 74% (n = 17) CG: 46% (n = 10)
Wong et al., 2012(⁴³43. Wong IKY, Andriessen A, Charles HE, Thompson D, Lee DTF, So WKW, et al. Randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers. J Eur Acad Dermatol Venereol. 2012;26(1):102–10. doi: http://doi.org/10.1111/j.1468-3083.2011.04327.x. PubMed PMID: 22077933. https://doi.org/10.1111/j.1468-3083.2011... )	RCT	Short-stretch bandage (n = 107)	4-layers (n = 107) Usual care^ΔΔ ΔΔCG2; (n = 107)	24	Healing rate IG: 72% (n = 77) CG1: 67.3% (n = 72) CG2: 29.0% (n = 31) *Healing time^ weeks; p < .001* IG: 9.8 (± .77) CG1: 10.4 (±.80) CG2: 18.3 (±.86) VU area difference^### ### ≠ initial-final VU area; IG: 2.85 (±8.18) p = .67 CG1: 3.39 (±8.64) p = .16 CG2: 6.90 (±10.62) p = .047
Luz et al., 2013(⁴⁴44. Luz BS, Araujo CS, Atzingen DA, Mendonça AR, Mesquita M. Evaluating the effectiveness of the customized Unna boot when treating patients with venous ulcers. An Bras Dermatol. 2013;88(1):41–9. doi: http://doi.org/10.1590/S0365-05962013000100004. PubMed PMID: 23539002. https://doi.org/10.1590/S0365-0596201300... )	Cohort	Unna’s Boot (n = 32)	Usual care (n = 11)	12	UV area difference^# ♦multicenter RCT; p > 0.05 IG: –47.12 (95% CI –100–107.41) CG: –53.06 (95% CI –100–57.96)
Macedo et al., 2013(⁴⁵45. Macedo EB, Torres GV, Oliveira AA, et al. Custo-efetividade da terapia compressiva em pessoas com úlceras venosas. Rev Enferm UFPE On Line. 2013 [cited 2024 Jan 9];6:101–7. Available from: https://periodicos.ufpe.br/revistas/index.php/revistaenfermagem/article/view/12244 https://periodicos.ufpe.br/revistas/inde... )	Cohort	Unna’s Boot (n = 18)	without comparator	10	VU area difference^# #% reduction; p = .000 IG: 73.5% (± 25.9)
Ashby et al., 2014(⁴⁶46. Ashby RL, Gabe R, Ali S, Adderley U, Bland JM, Cullum NA, et al. Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): a randomised controlled trial. Lancet. 2014;383(9920):871–9. doi: http://doi.org/10.1016/S0140-6736(13)62368-5. PubMed PMID: 24315520. https://doi.org/10.1016/S0140-6736(13)62... )	ECR^♦♦♦ ♦♦♦multicenter pragmatic RCT;	2-layer elastic stockings (n = 230)	4-layers (n = 224)	53	Healing ratep = .96 IG: 71% (n = 163) CG: 70% (n = 157) Healing time^ days; p = .96 IG:99 (95% CI 84–126) CG: 98 (95% CI 85–112)
Dolibog et al., 2014(¹⁷17. Dolibog P, Franek A, Taradaj J, Dolibog P, Blaszczak E, Pollak A, et al. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. Int J Med Sci. 2014;11(1):34–43. doi: http://doi.org/10.7150/ijms.7548. PubMed PMID: 24396284. https://doi.org/10.7150/ijms.7548... )	RCT	Unna’s Boot (n = 30)	Pneumatic compression^Δ ΔCG1; (n = 28) Ulcer X Kit^ΔΔ ΔΔCG2; (n = 30) Short-stretch multi-layer bandage^ΔΔΔ ΔΔΔCG3; (n = 29) 2-layers stretch bandage^ΔΔΔΔ ΔΔΔΔCG4. (n = 30)	NI	Healing rate p = .03 IG: 20% (n = 6) CG1: 57.14% (n = 16) CG2: 56.66% (n = 17) CG3: 58.62% (n = 17) CG4: 16.66% (n = 5) VU area difference^### ### ≠ initial-final VU area; IG: 15.78 (±19.57) p = .03 CG1: 10.13 (±20.88) p = .01 CG2: 9.67 (±20.02) p = .01 CG3: 8.12 (±17.23) p = .01 CG4: 16.27 (±20.23) p = .03
Finlayson et al., 2014(⁴⁷47. Finlayson K, Miaskowski C, Alexander K, Liu WH, Aouizerat B, Parker C, et al. Distinct wound healing and quality-of-life outcomes in subgroups of patients with venous leg ulcers with different symptom cluster experiences. J Pain Symptom Manage. 2017;53(5):871–9. doi: http://doi.org/10.1016/j.jpainsymman.2016.12.336. PubMed PMID: 28063868. https://doi.org/10.1016/j.jpainsymman.20... )	RCT	4-layers (n = 53)	Class III elastic stockings (n = 50)	24	Healing ratep = .14 IG: 84% (n = 45) CG: 72% (n = 36) *Healing time^ weeks; p = .03* IG:10 CG: 15 UV area difference^# ♦multicenter RCT; p = .27 IG: 96% (±15.6) CG: 93% (±14.9)
Lullove and Newton, 2014(⁴⁸48. Lullove EJ, Newton E. Use of a novel two-layer bandage in the treatment of chronic venous hypertension. J Am Coll Clin Wound Spec. 2014;5(1):8–13. doi: http://doi.org/10.1016/j.jccw.2014.05.001. PubMed PMID: 26199883. https://doi.org/10.1016/j.jccw.2014.05.0... )	Retrospective cohort	Unna’s Boot (n = 60)	without comparator	12	VU area difference^## ##(cm2/week); p < .001 IG: 63.3%
Salome et al., 2014(⁴⁹49. Salome GM, Brito MJ, Ferreia LM. Impact of compression therapy using Unna’s boot on the self-esteem of patients with venous leg ulcers. J Wound Care. 2014;23(9):442–6, 446. doi: http://doi.org/10.12968/jowc.2014.23.9.442. PubMed PMID: 25284296. https://doi.org/10.12968/jowc.2014.23.9.... )	Cohort	Unna’s Boot (n = 50)	without comparator	53	Healing rate p = .0001 IG: 84% (n = 42)
Abreu and Oliveira, 2015(¹⁰10. Abreu AM, Oliveira BGRB. Estudo da Bota de Unna comparado à bandagem elástica em úlceras venosas: ensaio clínico randomizado. Rev Lat Am Enfermagem. 2015;23(4):571–7. doi: http://doi.org/10.1590/0104-1169.0373.2590. PubMed PMID: 26444157. https://doi.org/10.1590/0104-1169.0373.2... )	RCT	High compression elastic bandage (n = 9)	Unna’s Boot (n = 9)	13	VU area difference## p < .0001 IG:42,32% CG: 69.41%
Guest et al., 2015(⁵⁰50. Guest JF, Gerrish A, Ayoub N, Vowed K, Vowden P. Clinical outcomes and cost-effectiveness of three alternative compression systems used in the management of venous leg ulcers. J Wound Care. 2015;24(7):300–8, 302–5, 307–8 passim. http://doi.org/10.12968/jowc.2015.24.7.300. PubMed PMID: 26198552. https://doi.org/10.12968/jowc.2015.24.7.... )	Retrospective cohort	2 cohesive layers (250)	2-layers^Δ ΔCG1; (n = 250) 4-layers^ΔΔ ΔΔCG2; (n = 175)	24	Healing rate IG: 51% (n = 128) – IG x CG1 p = .03 CG1: 40% (n = 100) – CG1 x CG2 p = .05 CG2: 28% (n = 49) – IG x CG2 p = .001 Healing time^* *months; IG: 2.5 (±0.2) CG1: 2.4 (±0.2) CG2: 2.5 (±0.3) UV area difference# IG: 60% CG1: 58% CG2: 57%
Januário et al., 2015(⁵¹51. Januário VF, Carneiro SCS, Silva MR. Avaliação comparativa da eficácia da bota de unna, do ácido tricloroacético a 90% e da carboximetilcelulose a 20% e suas repercussões socioeconômicas [thesis]. Rio de Janeiro: Universidade Federal do Rio de Janeiro: 2015.)	RCT	Unna’s Boot (n = 30)	90% trichloroacetic acid^Δ ΔCG1; (n = 30) 20% carboxymethylcellulose^ΔΔ ΔΔCG2; (n = 30)	20	Healing rate IG: 43% (n = 13) CG1: 13.3% (n = 4) CG2: 6.7% (n = 2) VU area difference^# #% reduction; p < .022 IG: 66.9 (±6.5) CG1: 46.4 (±5.8) CG2: 44.7 (±5.0)
Coutinho, 2019(⁵²52. Coutinho NB. O impacto da terapia de compressão elástica na cicatrização, dor e qualidade do sono em indivíduos com úlceras venosas [dissertation]. Guarulhos: Universidade de Guarulhos; 2019.)	Cohort	High compression elastic bandage (n = 48)	without comparator	04	VU area difference^## ##(cm2/week); p < .001 IG: 72.9%
Gillet et al., 2019(⁵³53. Gillet JL, Guex JJ, Allaert FA, Avouac B, Leger P, Blaise S, et al. Clinical superiority of an innovative two-component compression system versus four-component compression system in treatment of active venous leg ulcers: A randomized trial. Phlebology. 2019;34(9):611–20. doi: http://doi.org/10.1177/0268355519833523. PubMed PMID: 30836836. https://doi.org/10.1177/0268355519833523... )	RCT^♦ ♦multicenter RCT;	2-layers (n = 47)	4-layers (n = 41)	16	Healing rate p < .001 IG 48.9% (n = 23) CG: 26.3% (n = 11) Healing time p = .03 IG: OR 3.01 (97.5% CI 1.1–8.6)
Folguera-Álvarez et al., 2020(⁵⁴54. Folguera-Álvarez C, Garrido-Elustondo S, Rico-Blázquez MM, Esparza-Garrido MI, Verdú-Soriano J, Antelo Brioso C, et al. Efectividad de la terapia compresiva de doble capa frente al vendaje de crepé en la cicatrización de úlceras venosas en atención primaria. Ensayo clínico aleatorizado. Aten Primaria. 2020;52(10):712–21. doi: http://doi.org/10.1016/j.aprim.2020.01.010. PubMed PMID: 32278578. https://doi.org/10.1016/j.aprim.2020.01.... )	RCT^♦ ♦multicenter RCT;	2-layers (n = 56)	Usual care (n = 37)	12	Healing rate IG: 57.1% (n = 32) CG: 67.5% (n = 25) Healing time^ days; p = .744 IG: 45 CG: 60
Mosti et al., 2020(⁵⁵55. Mosti G, Mancini S, Bruni S, Serantoni S, Gazzabin L, Bucalossi M, et al. Adjustable compression wrap devices are cheaper and more effective than inelastic bandages for venous leg ulcer healing. A Multicentric Italian Randomized Clinical Experience. Phlebology. 2020;35(2):124–33. doi: http://doi.org/10.1177/0268355519858439. PubMed PMID: 31234752. https://doi.org/10.1177/0268355519858439... )	RCT^♦ ♦multicenter RCT;	Inelastic stockings (n = 33)	2-layers (n = 33)	12	Healing rate IG: 78.7% (n = 26) GC: 69.6% (n = 23)
Stather et al., 2021(⁵⁶56. Stather P, Petty C, Langthorne H, Rayner E, Zhang J, Hayden K, et al. A randomised controlled clinical trial comparing the effectiveness of bandaging compared to the JuxtaCures™ device in the management of people with venous ulceration: feasibility study. Phlebology. 2021;36(7):505–14. doi: http://doi.org/10.1177/0268355520988226. PubMed PMID: 33435839. https://doi.org/10.1177/0268355520988226... )	RCT	Inelastic stockings (n = 20)	2-layers (n = 20)	26	Healing rate IG: 60% (n = 12) CG: 55% (n = 11) *Healing time^ weeks;* IG: 12.67 (±6.11) CG: 13.64 (±6.98)
Senet et al., 2022(⁵⁷57. Senet P, Addala A, Léger P, Chahim M, Malloizel J, Blaise S, et al. A new compression system for treatment of venous leg ulcers: a prospective, single-arm, clinical trial (FREEDOM). J Wound Care. 2022;31(9):734–47. doi: http://doi.org/10.12968/jowc.2022.31.9.734. PubMed PMID: 36113543. https://doi.org/10.12968/jowc.2022.31.9.... )	Multicenter cohort	Single-layer multicomponent bandage (n = 52)	without comparator	6	Healing rate IG: 18 (35%) Healing time^ days; IG: 33 (±12)
Souza et al. 2022(⁵⁸58. Souza EN, Alexandre SG, Silva RA, Araújo TM, Martins MG, Caetano JÁ. Processo cicatricial de úlceras venosas de difícil cicatrização em tratamento com bota de Unna. Rev Rene (Online). 2022;23:e72429. doi: http://doi.org/10.15253/2175-6783.20222372429. https://doi.org/10.15253/2175-6783.20222... )	Cohort	Unna’s Boot (n = 14)	without comparator	9	UV area difference^### ### ≠ initial-final VU area; p = 1.00 IG: 9.33 (±7.81)
Karanikolic et al., 2023(⁵⁹59. Karanikolic V, Ignjatovic A, Marinkovic M, Djordjvic L. The effectiveness of two different sub-bandage pressure values on healing and quality of life outcomes for patients with venous leg ulcers. Postepy Dermatol Alergol. 2023;40(1):47–53. doi: http://doi.org/10.5114/ada.2022.124709. PubMed PMID: 36909910. https://doi.org/10.5114/ada.2022.124709... )	RCT	Class III compression stockings (n = 56)	Elastic bandage + Class III compression stockings (n = 60)	24	Healing rate CG: 55% (n = 33)
Ulusoy and Iscan, 2023(⁶⁰60. Ulusoy S, Iscan HZ. The management of venous leg ulcers: effects of four-layer bandage system. Turk J Vasc Surg. 2023;32(3):147–52. http://doi.org/10.9739/tjvs.2023.09.026. https://doi.org/10.9739/tjvs.2023.09.026... )	Cohort	4-layers (n = 113)	without comparator	12	Healing rate IG: 30 (26.5%) *Healing time^ weeks;* IG: 23.2 (±13.8)

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[1] Corresponding author: Fernanda Peixoto Cordova, Avenida Ecoville, 190, Sarandi, 91150-400 – Porto Alegre, RS, Brazil, fernanda.peixoto.cordova@gmail.com