The Unna Boot: A Historical Dressing for Varicose Ulcers.

The German dermatologist Paul Gerson Unna (1850-1929) is a prominent figure in the history of medicine for pioneering modern dermatopathology and dermotherapy (Figure 1) (1). Aside from writing extensively on anatomy, histopathology, and treatment of skin diseases, he contributed to medicine in many other ways: he originated the idea of using coated pills to enhance local absorption in the intestine, introduced ammonium bituminosulfonate (ichthyol) and resorcinol into medicine, and described several skin conditions including seborrheic dermatitis. Moreover, in 1881 he established a private clinic in Hamburg, Germany, which became a leading expert center in the diagnosis and treatment of skin disorders, hosting postgraduate physicians from all over the world for training (2). Unna also was one of the first to work with pharmacology of dermatotherapeutic agents (1). With the help of pharmacists Paul Carl Beiersdorf (1836-1896) and Oscar Troplowitz (1863-1918), Unna greatly enriched dermatologic formulas with new ingredients (2). As an alternative option to the poorly tolerated compression bandages of his time, in 1885 he invented a special gauze bandage impregnated with a mixture of 15% zinc oxide in a glycogelatin-based paste for treatment of varicose ulcers. This mixture had drying and cooling effects as well as antipruritic effects due to its continuous slight pressure on the skin (1). After numerous tests on different forms of bandages in the following years, Unna presented a new form of skin-tone compression bandage at the Third International Congress of Dermatology in London in August 1896 and published a paper on the topic in the Wiener medizinische Wochenschrift (Vienna Medical Weekly) on 17 October 1896 (3). His bandage technique later became a widely recognized therapy because of its effectiveness and simplicity. Several companies subsequently introduced similar ready-to-use zinc bandages to the market after the turn of the century. Furthermore, in 1910 Unna's pupil Heinrich Fischer (1857-1928), MD also recommended a modified version of the Unna boot for deep vein thrombosis (1,4). Having partially lost its earlier prominence in the first phase of compression therapy, the historical paste dressing and its modified versions are still used effectively to contribute to quicker healing in patients with chronic venous ulcers, and are sometimes used for diseases such as nummular dermatitis, lichen simplex chronicus, and atopic dermatitis on the extremities (4,5). Although the current trend in the use of medical eponyms is likely to decrease in literature, the Unna boot is one of those that have been fortunate to survive, honoring its inventor's name.

History of venous leg ulcers.

To retrieve the history of venous ulcers and of skin lesions in general, we must go back to the appearance of human beings on earth. It is interesting to note that cutaneous injuries evolved parallel to human society. An essential first step in the pathogenesis of ulcers was represented by the transition of the quadruped man to Homo Erectus. This condition was characterized by a greater gravitational pressure on the lower limbs, with consequences on the peripheral venous system. Furthermore, human evolution was characterized by an increased risk of traumatic injuries, secondary to his natural need to create fire and hunt (e.g. stones, iron, fire, animal fighting). Humans then began to fight one another until they came to real wars, with increased frequency of wounds and infectious complications. The situation degraded with the introduction of horse riding, introduced by the Scites, who first tamed animals in the 7th century BC. This condition exhibited iliac veins at compression phenomena, favouring the venous stasis. With time, man continued to evolve until the modern age, which is characterized by increased risk factors for venous wounds such as poor physical activity and dietary errors (1, 2).

[Historical review of opinions on the nature of varicose veins and leg ulcers and their treatment]. / Historický prehled názoru na povahu a lécení varixu a bércových vredu.

The development and changes of opinions concerning the nature and treatment od varicose veins and varicose ulcers are summarized in this article covering a long period from the Greek antiquity till the 20th century. Whereas in the ancient times (Hippokrates, Celsus, Galen) the meanings did not contradict the contemporaneous knowledge, curious opinions dominated from the 11th till the half of the 19th century, obviously influenced by the humoral theory of Avicenna. The official teaching claimed that black bile and other bad humours collected in varicose veins. Bandaging was thought to push back these humours into the body and cause madness or other serious illness and, therefore, was refused. On the contrary, ulcers were considered to be a favourable condition because their function was to drain the bad humours. The fundamentals of modern surgical treatment of varicose veins were presented by Madelung, Trendelenburg and Babcock at the end of the 19th and the beginning of the 20th century. Trendelenburg deserves acknoledgement of having introduced physiological and pathophysiological reasoning into the field of phlebology. The conception of the role of incompetent calf perforators for the development of leg ulcers advocated by Cockett and others represents a derailment on the way of evidence based medicine. The substance of this theory, although supported by most autors till the present time, have been repeatedly confuted by exact hemodynamic measurements. Evidence based medicine whose basement was laid by Trendelenburg more than 100 years ago cuts a difficult way through the field of phlebology.

Úlcera venosa / Venous ulcers

Os autores fazem uma revisão bibliográfica sobre o manejo da úlcera venosa. Abordam etiologia, fisiopatologia, epidemiologia, história clínica, diagnóstico e tratamento