My coauthors and I appreciate the comments of Drs. Mayer and Hansen. Regarding the cost effectiveness and utility of the Unna boot, we would point out that the focus of our Clinical Inquiry was on the initial management of venous stasis ulcers and how best to promote healing.
Little data exist on Unna boot application alone. But it is likely that many of the compression therapy modality studies in the Cochrane meta-analysis included in our review featured Unna boot dressings as part of some form of multilayer compression therapy being evaluated.1
As Dr. Hansen observes, compression, the standard compression classes, and the minimal benefits of low pressure levels provided by the classic TED hose and OTC support hose should have been addressed. This information was not included in our review due to space limitations. This subject deserves a dedicated article, as there is a great deal of confusion about terminology and types of dressings.
Both the 2009 Cochrane meta-analysis1 and a 2012 update2 found that adding a component of elastic compression therapy results in faster ulcer healing compared with inelastic compression therapy alone. Venous ulcers treated with 4-layer bandages heal faster, on average, than those treated with short stretch bandages, and regular use of compression stockings lowers the risk of recurrence.3 Correcting underlying venous incompetency issues is certainly a consideration, particularly for ulcers that initially heal but later recur.
Mark Andrews, MD
Winston-Salem, NC