Ultraviolet Therapy

Introduction

 Ultraviolet therapy is a form of treatment commonly used to treat certain

skin disorders.
 It consists of irradiation of the patient with the UVA band of ultraviolet
light.
 The therapeutic application of ultraviolet (UV) portion of the
electromagnetic spectrum (or UV therapy) has been used for decades,
although the recognition of the therapeutic effect of sunlight, dates back
to ancient times, artificial UV radiation that allows precise dosing has only
been available since last century with UV-A in 1974, narrowband UV-B in
1984, UV-AB in 1985, and UV-A1 in 1992.
 Ultraviolet therapy has been reported to be very effective in destroying
bacteria and promoting wound healing and therefore a promising adjunctive
therapy for chronic wounds infected with resistant bacteria.
 Ultraviolet therapy is commonly used to treat conditions like, psoriasis,
atopic dermatitis, vitiligo, mycosis fungoides, and hand/feet eczema.
 Though there is evidence present for effectiveness of Ultraviolet therapy
in the management of wounds and other skin conditions and the significant
role physiotherapists play in its application, anecdotal evidence suggests
that this modality is not routinely applied for treatment in regular clinical
practice.

Description

 Ultraviolet Radiation (UVR) is a non-ionizing radiation that lies between

soft x-rays and visible light in the electromagnetic spectrum.
 It has a wavelength of 100 nm to 300/480 nm.
 The therapeutic part of ultraviolet spectrum is classified by International
Commission on Radiation (CIE).
 Ultraviolet radiation obeys the law that governs all the radiations, they
may reflect, scatter and are absorbed by molecular chromophores.
 The degree of absorption is generally greater for shorter wavelengths,
shorter wavelengths penetrate less deeply.
 Absorption depends on the thickness of the epidermis and any
pigmentation of the skin.
  Skin thickening due to lesions will result in increased scattering and
absorption and thus reduced penetration.

Types of ultraviolet radiations

On the basis of dominant biological effects displayed by each region as:

 UV - A 315 - 400 nm Encourage wound healing

 UV - B 280 - 315 nm Skin erythematous region
 UV - C 100 - 280 nm Germicidal region

Production of ultraviolet radiation

 The sun emits broad spectrum of ultraviolet radiation, including UV-A, UV-
B, UV-C.
 Both UV-A and UV-B reach the earth from the sun. However, UV-C is
filtered out by the ozone layer.

For therapeutic purposes, some form of generator is used to emit ultraviolet

radiation

Types of UVR Generators:

1. Mercury vapor lamp: It is a gas-discharge lamp that uses an electric arc

through vaporized mercury to produce light. These are used for the
production of ultraviolet rays for therapeutic purposes. There are two
types of mercury vapor lamp:
o Air cooled medium pressure mercury vapor (Alpene sun lamp) : It
is a U-shaped glass tube filled with argon gas at low pressure. A
small amount of mercury is enclosed in the tube. The tube is sealed
at both ends. Burner is made up of quartz as this material allows
passage of UVR and can withstand very high temperature. At the
end of glass tubes, electrodes are placed in metal caps. Step up
transformer is used to apply high potential difference i.e 400V
across two metal caps. Step up transformer (400V) used to apply
high potential difference across the two metal caps. There occurs
ionization of Argon gas that promotes movement of positive ions and
free electrons which constitute current flow across the tube.
Electrons move towards (+) electrode, positive ions move towards (-)
electrode and collision between moving ions and neutral argon causes
 further ionization of neutral argon gas (produce UVR). Flow of
current across the tube produces heat making vaporization of liquid
mercury (Hg). Hg vapor gets ionized by flow of current causing
further acceleration of flow of current. UVR produced by the
process of – -Ar Ionization -Hg Vaporization -Hg Ionization •This
process takes about 5mins for the emission of ultraviolet after the
burner is started. •When lamp is turned off, ions of Ar and Hg
recombine so that within the tube everything returns to its neutral
state.
o Water cooled mercury vapor lamp (kromayer lamp) : It is a water
cooled UV lamp which eliminate the danger of burn and absorb IR.
The lamp is surrounded by circulating distilled water to absorb IR. A
pump and a cooling fan are organized into body of lamp to cool water.
After using, water circulation should be continued for 5 minutes and
then burner is switched off to cool lamp. At the front of lamp’s
head, water is circulated between two quartz window, which allows
UV to emerge. Advantage- direct contact method- (safe as
circulating water absorb IR).

1. Fluorescent lamps: One major problem with the mercury lamp is that it
produces a certain proportion of short ultra-violet rays and modern
treatment regimen requires the use of long-wave ultra-violet without the
short wave to avoid side effects, hence various types of fluorescent tubes
have been designed. Each fluorescent tube is about 120 cm long and made
of a type of glass that allows long-wave ultra-violet to pass. The inside of
the tube is coated with a special phosphor and the spectrum of each
fluorescent tube depends on the type of phosphor coating. Here, if any
short ultraviolet radiation is produced it is absorbed by the phosphor and
is re-emitted at a longer wavelength. Depending upon which particular
phosphor is used, the output of the tube may be part UVB and part UV-A
or UV-A, as in the PUVA apparatus, but accurate control of the emitted
wavelength is possible.
2. Theraktin tunnel: The theraktin tunnel is a semi-cylindrical lamp, which
has four Fluorescent lamps mounted inside it, with each tube being
mounted in its own reflector, in a way that even radiation is produced to
allow treatment of whole body to evenly occur in two halves.
3. PUVA apparatus: It is usually used for treatment of psoriasis, where a
large amount of UVA, is required. The tubes in PUVA are usually mounted
in a vertical battery on a wall, or four sides of a box surrounding the
patient. This form of ultra-violet radiation is usually given two hours after
 the patient has taken a photoactive drug such as psoralen: hence the term
PUVA (psoralen ultraviolet A)

Dosage of ultraviolet radiation therapy

Dosage of ultraviolet radiation therapy depends on number of factors like;

 distance between lamp and the skin,

 angle at what the radiation touches the skin and
 the time for which skin is exposed to the radiation.

Degree of erythema post ultraviolet therapy is the deciding factor of the dose;

1. Dose E1 - causes mild pink appearance of the skin which lasts for up to 24
hours with no presence of skin edema or discomfort. E1 is also called as
MED - Minimal erythema dose. It is the smallest dose of ultraviolet
radiation to result in erythema that is just detectable by eye.
2. Dose E2 - is 2.5% of E1 and causes definite milk red appearance of the
skin that blanches on pressure which lasts for up to 2 days with no edema
but slight soreness and irritation of the skin and powdery skin
desquamation.
3. Dose E3 - is 5% of E1 and causes very red skin appearance with no blanch
of skin on application of pressure, it lasts for 3 to 5 days. Post dosage
some some edema is present at the area of application, also the application
area feels hot and painful with thin sheet like desquamation of skin.
4. Dose E4 - which is 10% of E1 and leads to angry red appearance of the
skin which lasts for a week. It also leads to formation of blisters on the
skin which is very painful. It also causes thick sheet like desquamation of
skin.

Calculation of dosage:

 E1 is determined from the skin test and the other erythemal doses are
calculated as follows:
o Suberythemal - 75% of E1
 E2 = 2.5×E1
 E3 = 5×E1
 E4 = 10×E1
 Double E4 = 20×E1
 E4 and double E4 are used on an open wound
Physiological effects of ultraviolet radiation therapy

1. Erythema because of dilation of the capillaries and arterioles.

2. Pigmentation or tanning of the skin
3. Desquamation or Increased skin growth
4. UVB can convert sterols in the skin to vitamin D, therefore increasing
the production of vitamin D in the body.
5. Prophylactic effect starts in the body as the resistance of the body to
infection is increased because of the stimulation of reticuloendothelial
system.
6. Ultraviolet radiation destroys Langerhan’s cell and stimulates the
proliferation of suppressor T cells, these immunosuppressive effects may
contribute to the development of skin cancer.
7. Strong dose of UVB and C radiation to the eyes can lead to conjunctivitis
and photokeratitis which in turn results in Irritation of the eye, a feeling
of grit in the eye, watering of the eye and aversion to light. (photophobia).
A strong dose of UVA may also lead to the formation of cataracts.
8. Prolonged exposure of UVR lead to, premature ageing of the skin, this is
especially so in the light -skinned people. It also decreases function of
sebaceous and sweat glands. The skin becomes wrinkled, dry and leathery.
9. Cancer: Carcinogenesis is a danger, as these rays may influence the DNA
and thus effect cell replication. Squamous cell carcinomas are a serious
side effect. Hence, Shorter ultraviolet waves should be avoided, and
course of treatment should not exceed four weeks. [1][2]

Therapeutic use of ultraviolet radiation therapy

 Psoriasis
 Acne vulgaris
 Eczema
 Chronic infection
 Vitiligo
 Treatment of vitamin D deficiency
 Pruritus

Contraindications of Ultraviolet radiation therapy

 Irradiation of the eyes

 Skin cancer
  Pulmonary tuberculosis
 Cardiac, kidney and liver disease
 Systemic lupus erythematosus
 Fever

Danger of Ultraviolet therapy

 Burn
 Premature skin aging
 Carcinogenesis
 Damage to eyes
 over dose of ultraviolet therapy
 Shock

Infrared Therapy
Introduction

 Infrared (IR) or thermal radiation is a band of energy in the complete

electromagnetic spectrum.

 IR are the radiations of longer wavelength than the red end of the visible
spectrum and extend to the microwave region, i.e., from 760 nm to 1 mm.

 IR radiation is generated by Sun. Many ancient therapies have utilized

sunlight for wound healing and pain relief.

 When Sun rays reach the ground, they get absorbed by gases or water
molecules in the atmosphere.

 The human body is made of 70% water, so it can potentially accumulate a

large amount of energy that could modulate biological processes by strong
resonant absorption of IR radiation from sunlight mediated by water
molecules.

 Any heated body emits infra red. Any material with temperature above
absolute zero emits IR.
  IR radiations are produced in all matter by molecular vibration; the
molecular movement causes infrared emission of different wavelengths and
frequencies.

 The frequencies at which maximum radiations are emitted are proportional

to the temperature which means the higher the temperature, the higher the
frequency and so shorter the wavelength.

The classification of the International Commission on Illumination (CIE) has three

sub-divisions for the IR radiation

 The Near infrared are also known as 'luminous' as they have some visible
light with wavelength of 770 to 1500 nanometers.

 The luminous source is found to be more effective in tissue-heating as it

penetrates deeper and energy is distributed in larger areas of the tissues.

 The Far infrared (FIR) also called non-luminous are within 1500nm to 0.1 mm.
The non-luminous with peak around 4000nm is absorbed in the skin.

 FIR wavelength is too long to be perceived by the eyes, however, the body
experiences its energy as a gentle radiant heat which can penetrate up to 1.5
inches (almost 4 cm) beneath the skin.

Production of Infrared
Different kinds of lamps are used for production of therapeutic infrared:

Non-luminous generator - An electric current is passed through a coil of wire

wound on an insulating material (like porcelain/fireclay) which produces heat. The
infrared emitter is placed at the focus of parabolic reflector to reflect the
radiations in an uniform beam. The heated wire and heated material emits IR. Non-
luminous requires some time to heat up before the emitted rays reach maximum
intensity and so must be switched on at an appropriate time prior to use[1] [8].

Luminous generators - IR is produced by incandescent lamps in the luminous

generator. The lamp consists of a wire filament (tungsten) enclosed in a glass bulb
that may be evacuated or filled with an inert gas at a low pressure. When an
electric current is passed through the tungsten filament, it gets heated and emits
IR, visible and few ultra-violet (UV) rays. The front of the bulb is red to filter out
shorter visible and UV rays[8].

Power varies, for smaller lamps is 250 to 500 W for both generators and for large
non luminous - 750 or 1000W and large luminous 600 to 1500 W.

Absorption and Penetration of IR

 Some rays are reflected from the skin surface. Some penetrate in the skin,
get scattered, refracted and ultimately absorbed in tissues.

 Water and protein in the tissues strongly absorb IR.

 Research suggests penetration of IR depends on the structure, vascularity,

pigmentation of skin and wavelength of the rays. Penetration depth is the
depth at which approximately 63% of radiation energy is absorbed.[1] Far
infrared rays penetrate up to 1.5 inches (almost 4 cm) beneath the skin.

Factors of Absorption and Penetration of IR

 Wavelength of rays

 Angle of incidence of ray

 Distance from source of infrared

 Density of tissue
Physiological Effects

Infrared radiations cause:

 Local cutaneous vasodilation due to the release of chemical vasodilator

(histamine) as well as possible effect on the blood vessels, occurs after 1-2
minutes.

 Evident erythema. The rate and intensity of erythema depends on rate and
degree of heating.

 Reflex dilation of other cutaneous vessels occurs to maintain normal heat

balance.

 Prolonged heating leads to sweating and eventually to cooling.

Therapeutic Uses

Infrared is used for the following purposes:

 pain relief

 decreases muscle spasm

 increases the sensory nerve conduction velocity, increase in endorphins

influencing the pain gate mechanism

 acceleration of healing and tissue repair- pressure sores

 used prior to electrical stimulation/testing or biofeedback to make the skin

a better conductor

Application
 Patient is placed in a comfortable position and the area to be treated is
exposed. Nature and effects of treatment are explained. Skin is examined
and thermal sensations are tested. Eyes are shielded in case they are
irradiated. To achieve maximum penetration, the lamp is placed at right
angles to area to be treated.[1]Distance from the lamp can be about 60-75
cm for large lamp (750-1000W) and 45-50cm for smaller ones. Intensity of
heat is controlled by altering the position of the lamp or in some lamps by
altering the resistance thereby the current to the element. Non-luminous
 lamp has to be switched on up to 15 minutes before application to allow
maximum emission.
Dangers
 Burns
 Skin irritation
 Eye damage
 Dehydration
 Low BP
 Electric shock
 Headache
 Defective arterial blood flow
Indications
 Osteoarthritis
 Rheumatoid arthritis
 Ankylosing spondylitis
 Capsulitis
 Psoriasis
 Joint stiffness
 Odema
 Pain
 Muscle spasm
Contraindications
 Impaired cutaneous thermal sensations
 Defective arterial cutaneous circulation
 Dermatitis or eczema
 Tumors
 Skin damage due to ionizing radiation
 Tuberculosis
 Photosensitivity
 Hyperesthesia
 Mental retardation
 Metal implant
 Fever