Shruti Shah Agnes Roubin SYBPTh

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 Def:- Ultraviolet radiation is electromagnetic energy, which is invisible to human eye, with wavelengths between 10nm to 400nm. Ultraviolet are usually defined in terms of their wavelengths, extending the violet end of the visible at 390nm to 400nm to the soft X-ray.

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 UVR behave in a similar way to visible radiations in the way they are reflected, refracted or absorbed, except that they are more strongly absorbed in air, in particular the short-wavelength ultraviolet. UVR can cause sunburn and tanning on exposure to the sunlight.

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REGION

WAVELENGTH

OTHER NAMES BIOTIC Long uv black light. Medium UV Erythemal UV ABIOTIC Short UV Germicidal UV
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UV A UV B

400nm 315nm 315nm280nm

UV C

280nm100nm

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 Incandescent sources, like sun, can produce UVR if the temperature is high enough. However, it is usually produced by the passage of a current through an ionized vapour-often mercury vapour. Gases do not conduct current well at normal temperatures and pressures but can be made to do so at low pressure or high temperatures.

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 It consists of U-shaped glass tube filled with argon at low pressure. Small amount of mercury is enclosed in the tube and the tube is sealed from both the ends. The burner is made of quartz as this material allows the passage of ultraviolet rays and can withstand very high temperatures with low coefficient of expansion. At the ends of the glass tube, electrodes are placed enclosed in the metal caps across which a high potential difference is applied in the argon gas.

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 A step up transformer is used to apply very high potential difference i.e. 400volts across the two metal caps surrounding ends of tube to ionize the argon gas. Once the argon gas is ionized, normal mains voltage between the electrodes causes positive and negative particles to move through the burner, constituting an electric current

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 The electrons move positive pole positive ions move negative pole The collision between moving ions and neutral argon atom causes further ionization and a glow discharge is produced. Also, sufficient heat is produced to vaporize the liquid mercury inside the tube and further ionization of mercury. When the lamp is turned off, the ions of mercury and argon combine so that within tube everything returns to its neutral state.

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THE TRYDIMITE FORMATION:- some of the quartz changes to one another form of silica called trydimite due to very high temperature in the burner. It is harmful to the total output of UV rays as it is opaque to the rays and the total output of the lamp gradually decreases as the proportion of trydimite increases at around 1000hrs of UV rays production that much trydimite can form that the whole burner need to be replaced. A variable resistance is included in the burner circuit as a method of compensation and resistance is reduced in order to increase the current .

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 This lamp in in the form of u-shaped tube. This lamp is also known as high altitude lamps or alpine sunlamp. They emit continuous spectrum of visible and IR radiations. This precludes placing them close to the skin unless they are cooled. The U-tube of alpine sunlamp is set at the centre of a parabolic reflector and made of a special aluminium alloy supported on a strong stand.

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 Short UVR reacts with oxygen in free air to form ozone, which is evident from its smell, even at low concentrations. Ozone is toxic at high concentrations so ventilation should be adequate around this lamps. In some modern lamps the burner envelope is modified so that it does not emit ozone producing ultraviolet below 270nm.

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 The Kromayer lamp is a medium pressure mercury vapour ultraviolet lamp designed to be used in contact with the tissues and body cavities. CONSTRUCTION: the Kromayer lamp is a water cooled mercury vapour lamp which eliminates the danger of burn and absorbs infrared rays. The high pressure mercury lamp is surrounded by circulating distilled water so as to absorb infrared rays. Kromayer lamp can also be used to treat sinuses or deep body cavities. Direct contact methods can also be used as it minimizes the danger of burn.

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 Mercury vapour lamp has disadvantage that it produces a certain proportion of short ultraviolet rays. Modern treatment methods often require the use of long ultraviolet rays. In order to achieve this fluorescent tubes are used. Each tube is about 120cm long and made up of glass which allows the passage of long UVR.
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 The inside tube is coated with special phosphor. The spectrum of each tube depends upon the coating of phosphor. A low pressure arc is set up inside the tube with the help of ionization. Phosphor is used to absorb short ultraviolet and waves are emitted at longer wavelengths.

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 THERAKTIN TUNNEL:- the teraktin tunnel is semi-cylindrical frame work in which 4 fluorescent tubes are mounted in its own reflector in such a way that even irradiation of a patient is achieved. Normally fluorescent tubes with a spectrum of 280400nm.

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 PUVA apparatus :-Irradiation with UVA only, may be performed with special fluorescent tubes which may be mounted in a vertical battery on a wall or on four sides of a box totally surrounding the patient. This form of UV rays are usually given for two hours after the patient has taken a photo-active drug such as psoralen , hence the term PUVA( Psoralin-ultraviolet-A) is used.

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 The energy transmitted by UVR can be measured to investigate the output of the ultraviolet lamps and quantify treatment. The output of a UV lamp is normally specified in terms of its irradiance, which is the output power per unit time. The standard unit of irradiance in UV lamp is the watts per square centimeter(W/cm2). Both the irradiance and the wavelength is quantifiable.

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 A device called photometer is used to measure the irradiance and by using filters the output over specific wavelength ranges can be measured. The radiant exposure is the irradiance multiplied by the time of exposure(in seconds). The units of radiant exposure are thus joules per square(J/cm2). Radiant exposure (J/cm2) = Irradiance (W/cm2) time of exposure(sec). Irradiance = power delivered per unit area(W/cm2).

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 TEST DOSE:- individual patients reaction to the UVR is used to access the test dose. Calculation of test dose by air cooled lamp:- A suitable area of forearm is used for calculation of test dose. The skin is washed to remove any dust or grease. Three differently shaped holes are cut with a material which is resistant to the passage of UVR.

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 The size of the middle hole is about 2cm2cm with the hole on one side larger and on the other side smaller. A number of people are tested to find out average E1 time and distance by seeing a erythema reaction. The term E1 first degree eythema and minimal erythemal dose refer to the response used to define a dose. They are also used to define the subsequent t/t doses.

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 By knowing average E1 (time and distance) for particular lamp , the duration of E2, E3 and E4 doses can be calculated. E2 time =E1 time 2.5 E3 time = E1 time 5 E4 time = E1 time 10 Also by inverse square law half the distance requires quarter the time for having the same effect.

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1. The cut out paper or lint is applied to patients forearm and the body is screened. The middle hole receives the calculated E2 dose. 2. The small hole receives an exposure slightly longer than E2 and the larger hole receives an exposure slightly shorter . 3. The procedure is carefully recorded in patients t/t card.

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 All three holes are given to the patient to record when the eythema appears, how severe it is and how long it lasts. CALCULATION OF TEST DOSE BY THERAKTIN TUNNEL:- Same procedure is used to calculate the test dose as mentioned above, however larger holes of about 4cm 4cm are used and placed on the abdomen. The rest of the body is screened.

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 CALCULATION OF TEST DOSE BY KROMAYER LAMP:- Since the kromayer lamp is used in contact with the skin, the test dose is calculated by using very small holes, i.e. 0.25cm 0.25cm and the exposure time needs to be very short.

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Degree of eythema

Approx. latent period 6 12 hrs

Appearan Approx ce duration of erythema Mildly pink <24 hrs

Skin edema

Skin Desquam discomfort ation of skin None None

E1

None

E2 = E1 2.5

6 hrs

Definite pink-red Blanches on pressure Very red does not blanch on pressure Angry red

2 days

None

Slight soreness irritation

Powdery

E3 = E1 5

3 hrs

35 days Some

hot and painful

In thin sheets

E4 = E1 10
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< 2 hrs

week

blister

Very painful

Thick sheets.
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1. Patient : A test dose having been completed, the nature and effects of the treatment are explained. 2. Apparatus : A suitable plinth is kept in position so that the Theraktin tunnel or the lamp can be placed a standard distance (usually 50cm) from the area to be treated.

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3. Setting up : If a general body treatment, the patient undresses completely, puts on ultraviolet goggles. Limbs must not shade one another or the trunk. If using a tunnel, the distance between the patient and the tubes is measured. The position of the patient must be repeatable from one treatment to next. If the treatment is localized, the area should be exposed and the patient should wear protective goggles.

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4. Instructions and warning : The patient is asked to keep still and not touch the tunnel or the lamp. 5. Application : The UVR source is switches on for appropriate time for the required dose. If a lamp is used it should be turned on for at least 5 minutes before the treatment to stabilize the output. 6. Progression : This has 4 separate components. These are :
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Duration of subsequent treatments The dose is increased by prolonging the duration (time) of successive treatments. If for example, an erythema occurs after a suberythemal treatment the next dose should be reduced. Size of area treated The size of area treated depends on the level of E given Total number of treatments this is usually limited as it is balance between the benefits of UVR and risks. Progression cannot be continued as protective changes will reach their maximum at some stage. Adjusting for missed treatments - if for any reason the regular treatments are missed for a time some of the protective pigmentation and skin thickening is lost. It is usual to presume all protective effect is lost over 4 weeks.
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 The well-known acute effects of the sun, i.e., sunburn, are really the effects of UVB radiations. Ultraviolet radiations are largely absorbed in the outer layer of the skin so that the direct effects are limited to those on the skin and the eyes. The penetration depth of UVC is approximately 40 50 m, while 10% of UVB and 40% 50% of UVA penetrates to the basal layer.

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 The degree to which these effects occur depends on: 1. The amount of UVB energy applied 2. The radiant exposure 3. The reactivity or sensitivity of the skin of the subject These effects can be considered in two groups: 1. The immediate or acute effects occurring within hours, days, or weeks 2. The long-term chronic effects noted only after years. OR 1. Local effects 2. General effects
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1. Erythema : An erythema or redness of skin appears sometime after application of the UVR. This is often after a matter of hours and is called the latent period. Over some hours the erythema increases and then fades during the subsequent hours or days. The redness caused by UVR is uniform, not mottled, and there is a distinct edge at the junction with an unexposed area. Damage to cells causes release of histamine like substance from the dermis and the epidermis. The greater the quantity of the chemical, the sooner and fiercer is the reaction.

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 A gradual diffusion of this chemical takes place until sufficient amount has accumulated around the blood vessels in the skin to make them dilate. This accounts for latency of erythema. Although after sufficient exposure to UVA some immediate erythema may occur. Erythema reaches maximum intensity between 8 to 24 hours after exposure but may take several days to resolve completely. It is produced by wavelengths shorter than 315nm.

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2. Pigmentation (tanning) : Pigmentation of the skin occurs as a result of both the formation of melanin in the deep region of the epidermis and the migration of melanin already formed into more superficial layers. Melanin pigmentation of the skin is of two types : 1. constitutive and 2. facultative

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 The skin type system is used widely to choose a starting dose of UVR. The categories of skin type system are :  Group 1 always burns, never tans  Group 2 always burns, sometimes tans  Group 3 sometimes burns, always tans  Group 4 never burns, always tans  Group 5 moderate racial pigmentation (e.g. Asian skin)  Group 6 marked racial pigmentation (black skin) The increased melanin content of the skin affords protection by preventing UVR reaching the lower layers of the epidermis where the dividing keratinocytes are situated.

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3. Hyperplasia (increased skin growth) : Stimulation by UVR provokes increased keratinocyte cell turnover so that the skin grows more rapidly for a time, leading to shedding of the most superficial cells at an earlier stage in their development than usual so that they remain in pieces, or even sheets, and can be peeled off. This begins to occur after around 72 hours of exposure, is a result of increased rate of division of basal epidermal cells. This adaptive process occurs with all skin types and is a major factor that protects those who tan poorly. It occurs generally in UVB exposure. The peeling or desquamation varies with the intensity of the applied UV radiation. Both these protective effects fade over 4-6 weeks if there is no further UV application.
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4. Vitamin D production : UVB is able to convert sterols in the skin, such as 7-dehydrocholesterol to vitamin D which, after changes in the liver and kidneys, is able to facilitate the absorption of calcium from the intestine. The UVB radiations are most effective for vit. D production in the 280nm and 300nm regions. Suberythemal doses of UVB are adequate to promote vitamin D synthesis. 5. Immunosuppressive effects : An UVR appears to trigger immunosuppressive effects, both locally and systemically.
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 This occurs because UVB destroys Langerhans cells and stimulates proliferation of suppressor T cells. When organisms invade the skin, macrophage like Langerhans cells gather some of the pathogen and transport it to the lymph nodes, which send out specific killer T cells. Suppressor T cells inhibit antibody production and suppress action of other T cells. This immunosuppressive effect is believed to be the protective response to prevent an autoimmune attack on the skin cells that have been altered by UVR. These effects may contribute to the development of skin cancer.

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1. Solar elastosis and ageing : Chronic exposure to sunlight can result in the appearance of the skin often referred to as premature ageing or actinic damage. The clinical changes associated with skin ageing include a dry, coarse, leathery appearance, laxity with wrinkling, and various pigmentary changes.
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2. Cancer : The three most common forms of skin cancer listed in order of seriousness, are : basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Carcinogenesis is a danger if long exposure to UVB and C occurs, as these may have an effect on DNA and thus cell replication. Therefore, prolonged exposure should be avoided and courses of treatment should not exceed four weeks.

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1. Photokeratitis and conjunctivitis : These are usually due to acute exposure to UVB and UVC. Conjunctivitis is an inflammation of the membrane that lines the insides of the eyelids and covers the cornea, often accompanied by erythema of akin around the eyes. There is sensation of gritty eyes and often photophobia, lacrimation and blepharospasm.

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 Photokeratitis is an inflammation of the cornea that can result in severe pain. The acute symptoms of visual incapacitance last from 6-24 hours. Almost all discomfort disappears within 2 days and rarely does result in permanent damage.

Photokeratitis
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2. Cataract : UVA irradiation can lead to cataract formation, and for this reason adequate eye protection should be worn during treatment.

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1. 2. 3. 4. 5. 6. 7. 8.

Psoriasis Acne vulgaris Eczema Infected wound Vitiligo Protection for hypersensitive skin Treatment for vitamin D deficiency Treatment for mild hypertension

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9. Treatment for pruritus 10. Non-infected wounds 11. Intact skin 12. Pressure sores 13. Alopecia 14. Rickets 15. Counter irritation effect 16. Physiological benefit

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 Skin develops an increased sensitivity to UVR following ingestion or topical application of a number of different substances. This has 2 important implications : 1. Prior to erythema testing the therapist must record all the current medications and clean the skin of any topical substances not required for test or treatment. 2. Care needs to be exercised if a patients drug regimen has been altered during the course of UV treatment. The commonly encountered topical and systemic photosensitizers are : 1. Diuretics e.g. furosemide
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2. Anticancer drugs e.g. methotrexate 3. Antidepressants e.g. tricyclics 4. Antifungals e.g. griseofluvin 5. NSAIDs e.g. ibuprofen, naproxen, celocoxib 6. Antibiotics e.g. sulphonamides, tetracyclins 7. Retinodis e.g. used in conjunction with UVR treatment 8. Hypnotics e.g. sulphonalm 9. Coal tar used as a sensitizer to UVR psoralens 10. Cold therapy 11. Aspirin and derivatives 12. Strawberry 13. Eosin
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 Acute skin condition acute eczema, dermatitis and an existing UV erythema Skin damage due to ionizing radiations deep x-ray therapy Systemic lupus erythematosus can be triggered. Photoallergy allergic reaction to UVR Acute febrile illness whole body treatment should be avoided Recent skin grafts Known cases of tumors

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1. Eyes : Eyes of the patient should be protected as there is danger of conjunctivitis formation or cataract to occur UVB and UVC are absorbed by the cornea but UVA is absorbed by lens and is implicated in the form of cataract. The therapist should also wear protective goggles.

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2. Overdose : There are a number of factors due to which the patient can receive overdose during treatment.  Too long exposure  Moving the lamp closure to the patient  Changing the lamp  Use of sensitizers  Using a lamp with stronger output  Poor technique  Previously protected skin being irradiated at subsequent treatments The effects of overdose do not appear for sometime. But if overdoes is suspected, infrared radiation may be given to the area in an attempt to increase blood circulation and disperse histamine-like substance that produces erythema.
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Dr. Sagar Naik (PT) notes Sheila Kitchen Jagmohan Low and Reed Clayton 9th edition Wikipedia.org Google images

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THANK YOU

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