Inframalleolar venous ulcers heal with Unna boot therapy

This study highlights the presentation of inframalleolar ulcers in venous disease, their wound healing factors, recurrence rate, and response to Unna boot treatment with adjunct endovenous and/or iliac vein stenting treatments.

This retrospective single-center study included 71 office-based patients with inframalleolar venous ulcers treated between May 2012 and May 2023. Of the 71 patients evaluated, 12 presented with bilateral ulcers, resulting in a total of 83 limbs treated. Patient demographics including age, sex, ulcer etiology, ulcer location, diabetes status, and treatment modality were evaluated. All patients presented with bilateral leg swelling and venous reflux greater than 500 ms suggestive of venous insufficiency. Initially, patients were required to have palpable pedal pulses and a normal ankle-brachial index (ABI) for inclusion. Over time, inclusion criteria were broadened to accept patients with mixed arterial venous disease, provided their ABI was greater than 0.6. Patients with isolated arterial pathology and an ABI <0.6 and those with diabetic neuropathic ulcer etiology were excluded from this study. Patients received compression therapy that included an elastic all-cotton elastic wrap and an inelastic Unna boot formulated with calamine, zinc oxide, and glycerin, both applied by trained medical assistants. Sixty-five patients received additional endovenous and/or iliac vein stenting treatments.

The mean patient age was 67 ± 14 years (range, 25-96 years). Of the 71 patients treated, 12 (16.9%) presented with ulcers on both limbs, resulting in a total of 83 limbs treated. All ulcers were treated with weekly Unna boots, with an average treatment duration of 12 ± 23 weeks (range, 1-181 weeks) and a median treatment duration of 5 weeks. After wound healing, patients were followed for a mean duration of 16 ± 28 months. The success rate of >90% healing for inframalleolar ulcers was 51.8%. Factors associated with wound healing were ulcers that were primarily venous in nature as opposed to mixed (P = .01). Heel ulcers were not associated with inferior wound healing (P = .10) compared with other locations but were associated with higher rates of recurrence (P = .002). In total, 26.76% of patients had recurrent ulcers, whereas 45.13% did not; 8.4% of ulcers were still actively being treated with Unna boots, and 19.71% of patients were lost to follow-up. Improved healing of inframalleolar ulcers was significantly associated with the presence of a concomitant supramalleolar ulcer on the same limb (P = .02).

This study brings attention to the uncommon presentation of inframalleolar ulcers in venous stasis disease and is driven by the observation that bilateral leg swelling can lead to poor wound healing. Compression therapy using Unna boots is easily accessible, cost-effective, and should be considered as it offers significant therapeutic benefit in this patient population.