Development of a Manual on the Technique of Applying the Unna Boot in Patients With Venous Leg Ulcers

Edmundo Martins, Jr, RN, MS; Leila Blanes, RN, PhD; Christiane Steponavicius Sobral, MD, PhD; Lydia Masako Ferreira, MD, PhD


Wounds. 2021;33(1):28-33. 

In This Article

Abstract and Introduction


Introduction: Providing adequate care for people with venous leg ulcers (VLUs) can be a challenge. Numerous publications have discussed the importance of compression therapies on the treatment of VLUs, but few have described the necessary materials and techniques for applying the Unna boot, contributing to the underutilization of this therapy. The use of manuals is one of the strategies in the training of health professionals.

Objective: The aim of this study was to develop and validate a manual on the technique of applying the Unna boot in patients with VLUs. The manual was created to improve the education and training of health professionals in the control of chronic VLUs.

Materials and Methods: This was a descriptive study involving 3 stages. The selection of content for the manual was based on a literature review of articles in the Portuguese, Spanish, and English languages published from January 2000 through December 2018, in which 8 key terms were searched across the Cochrane Library, MEDLINE, and SciELO databases, and Google Scholar search engine. The text, illustrations, and layout design of the manual as well as a video demonstration of the technique were created. The manual then was validated for content by an expert panel using the Delphi Technique and the content validity index (CVI).

Results: The manual showed an overall CVI of 0.98 after 2 rounds of consultation and its content, presentation, and relevance were rated as very adequate by the expert panel. The final version of the manual features 29 pages of text and illustrations and includes a video demonstration of the technique.

Conclusions: A manual on the technique of applying the Unna boot in patients with VLUs was developed and validated for content by an expert panel.


A venous leg ulcer (VLU), also known as a varicose ulcer, stasis ulcer, or phlebostatic ulcer, is the most common ulcer of the leg, accounting for about 70% of all ulcerations.[1] It usually occurs in the medial aspect of the leg as a result of chronic venous insufficiency and venous hypertension in the standing position.[2–5] The clinical features of VLUs include increased skin temperature of the lower extremities, edema, varicose veins, and skin changes, such as stasis eczema, skin sclerosis, and hyperpigmentation, especially in the malleolar region and distal third of the leg.[2] Venous ulcers usually present with slow progression, infiltration at the edge of the ulcer, slough in the wound bed, and, in most cases, secondary infection.[3] In general, the ulcer arises after trauma and may be preceded by erysipelas, cellulitis, and/or stasis eczema.[3–5]

Venous leg ulcers may occur in people of productive age.[4] In many cases, individuals with VLUs withdraw from work, which can exacerbate socioeconomic conditions,[4] potentially making those with VLUs unable to afford care. This condition also can cause several changes in lifestyle due to walking difficulty, pain, and the presence of wound exudate and odor, which may lead to changes in mood, family relationships, and social life.[6–8]

In 1882, German dermatologist Paul Gerson Unna developed a zinc oxide paste (Unna paste) to treat dermatitis associated with VLUs and later combined the paste with bandages (Unna boot), which became the principle of active compression therapy for VLUs. In the United States, the Unna boot is a widely used compression therapy for VLUs.[9,10] Over the past 30 years, the Unna boot has been commercialized as a product composed of an inelastic (no-stretch or short-stretch) bandage impregnated with a paste containing zinc oxide, glycerin, acacia, castor oil, and white petrolatum to prevent hardening, making the product flexible.[5] The bandage creates a high counter-pressure during walking and maintains a low resting pressure.[11] The bandage composition varies among different manufacturers and may contain cotton-viscose, nylon, polyester, or other materials in different proportions, thereby affecting the quality of the bandage in resisting static pressure, preventing edema, and decreasing venous hypertension.[12,13]

Compression therapy is considered the gold standard for the treatment of venous disease in many countries.[14] It significantly increases the healing rate of VLUs and reduces the risk of recurrence.[14] Despite its benefits, health professionals often use advanced technologies in the treatment of VLUs, with underutilization of compression therapy.[14,15]

The development of an effective educational tool for health professionals may improve the quality of care for patients and enhance wound healing by helping health professionals better understand the health care needs of a target population as well as propose actions for health promotion and effective interventions to address local problems.[16] All educational activities should be guided by a broad societal perspective, allowing ample possibilities for reflection.[17]

The aim of this study was to develop and validate a manual on the technique of applying the Unna boot in patients with VLUs for the use of health professionals.