Lecture III

ULTRAVIOLET RADIATION

Nature of ultraviolet radiation:

Ultraviolet radiation (UVR) covers a small part of the electromagnetic

spectrum. Ultraviolet radiation (UVR) are well recognized as wavelengths that
cause sunburn and tanning on exposure to the sun. UVR spans the wavelength
region from 400-100nm. Even in the ultraviolet portion of the spectrum the
biological effects of the radiation vary enormously with wavelength and for this
reason, the ultraviolet spectrum is further subdivided into three regions:
1- UVA: 400-320 nm.
2- UVB: 320-290 nm.
3- UVC: 290-200 nm.

The frequency ranges from 0.75 X 10 to 3 X 10 Hz.

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UVR behave in similar way to visible radiations in the way they reflected,
refracted or absorbed, except that they are more strongly absorbed in air, in
particular the short-wavelength ultraviolet. Thus much of the short UVR emitted
by the sun never reach the surface of the earth.

Production of UVR:
The sun is the natural source of UVR. The therapeutic UVR are produced by
mercury vapor lamps, which consists of a quartz burner tube evacuated from air
and containing traces of argon gas and mercury under reduced pressure. An
electrode is inserted at each end of the burner tube. The current is applied to the
electrodes, the mercury vaporizes and the passage of electrons through the vapor
establishes the ultraviolet arc. All ultraviolet lamps also produce visible light and
infrared rays heat the burner tube from 60°C to several hundred degrees. It is
necessary to incorporate a cooling device into the lamp, particularly if the lamp is
to be used close to or in contact with the patient. Devices commonly used include
air cooling (using air circulating fan), and water cooling (using a water jacket
surrounding the burner with continually circulating water).
The therapeutic UV apparatus:
1- Alpine Sun Lamp (air cooled lamp): this lamp is widely used in
physiotherapy department in the form of U-shaped tube. It is usually applied
at a distance of 45 or 50 cm. UVB is produced at 297, 302, 313 nm (medium
UV) used in treatment of generalized skin conditions as acne and psoriasis.
2- Kromayer lamp (water cooled lamp): this UV lamp is designed to be used in
contact with the tissues, both on the skin and in body cavities. The U-tube
Kromayer lamp is enclosed in a waterproof metal container with a quartz
window in front. Surrounding another metal container and quartz window:
water is pumped between the two windows. The doses of a few seconds
with the Kromayer can achieve the same effect as those of a few minutes
with the air-cooled lamp. Kromayer lamp give both give both UVB and
UVC, used for treating localized lesions as pressure areas, ulcers, shelves
and sinuses in open areas.
3- Fluorescent tubes (Theraktin lamp): consists of a number of fluorescent
tubes incorporate in a semicircular tunnel. It give both UVA and UVB and
used in treating psoriasis affecting large areas.

Physiological effects of UVR:

1- Local effects:
a- Erythema: is reddening of the skin as a result of an inflammatory
reaction stimulated by UVR leading to release of histamine like
substance which cause dilatation of the capillaries and arterioles and
exudation of fluids into the skin.
b- Pigmentation: tanning of the skin follows the erythema; its amount
varies with the intensity of the erythema. Pigmentation is due to the
increased deposition of the pigment melanin formed in the basal cell
layer of the skin by the melanoblasts, and migrates to the superficial
layers of the epidermis.
c- Desquamation: is the casting off of the cells which have been
destroyed by the UVR, desquamation is proportional to the intensity
of the erythema.
d- Growth of epithelial cells: is increased as a part of the repair process
which follows the erythema.
e- Antibiotic effects: destructive effects of ultraviolet radiations include
the destruction of viruses, bacteria and other small organisms on the
skin surface.
2- General effects:
a- Formation of vitamin D: UVB is able to convert sterols in the skin
such as 7-dehydrocholesterol to vitamin D which able to facilitate the
absorption of calcium from the intestine. Insufficient vitamin D leads
to rickets in babies and osteomalacia in adults.
 b- The esophylactic effect: the resistance of the body to infection is
increased as a result of stimulation of reticulo-endothelial system
which increases antibodies against bacteria and toxins.
c- Variation in responses to UVR: depends on skin type, degree of
pigmentation and age of subject.
d- Natural protection against UVR: due to repeated exposure to UVR,
the sensitivity of the skin is reduced.

TEST DOSES
To treat patient accurate and effectively you must make test to determine the
minimal erythema dose or the dose should be given. Three holes of at least 2cm of2

different shape are cut in a piece of lint or paper. Put the paper on the tested area
and cover the surrounding areas. Use the E1 of the lamp as the test dose. Uncover
only one hole and expose it to E1 of the lamp, then uncover the second hole and
expose the both holes to E1, at least expose all holes to E1. The first hole was
exposed to E1 three times, the second hole exposed to E1 two times and the third
hole exposed to E1 only once. Mark on the holes before removing the paper.
Measure the distance between the lamp and skin. Instruct the patient, relative or
the nursing stuff to inspect the hole which was irradiated (pink or red) 6 to 8 hours
after exposure. The patient should be seen after 24 hours after the skin test. The
minimal erythema dose (MED) or E1 is determined as that area which appeared
erythmatous at 6 to 8 hours and which has just disappeared at 24 hours.

Test applied Monday Tuesday

11.00 am
Monday
3 p.m 7 p.m 11 p.m 7 a.m 11 a.m

Level of UVR erythema

1- First degree erythema (E1) or minimal erythema dose (MED): is the length
of the UV exposure required to produce a mild erythema which appears
within 6 to 8 hours and still just visible after 24 hours.
2- Second degree erythema dose (E2): is the length of UV exposure required to
produce an erythema which appears within 4 to 6 hours and disappear within
48 hours and a little discomfort may be felt.
3- Third degree erythema dose (E3): is the length of UV exposure required to
produce marked erythema which appears within 2 to 4 hours and lasts for
 72-96 hours. It resembles severe sunburn and associated with edema and
tenderness. Subsequent pigmentation and desquamation are marked.
4- Forth degree erythema dose (E4): is the length of UV exposure required to
produce an intense erythema which appears within 2 to 4 hours and may last
for a week or more. Edema and exudation of fluid into the tissue.
Calculation of dosage:
E1 is the basic of UV calculation which is determine for each individual by
performing a skin test. We must calculate the length of time in seconds and the
distance from the source of UVR to the patient’s skin in millimeter.
E1 is determined from the skin test and E2, E3, E4, are calculated using the
formulas:
• E2= 2.5 X E1
• E3= 5 X E1
• E4= 10 X E1
Example:
If the E1 of a patient is 25s at a distance of 100mm, calculate the E3 at
100mm.
E1= 25s at 100mm
E3= 5 X E1
E3= 5 X 25 = 125s at 100mm.
Progression of UV dosage:

Due to repeated exposure to UVR, the skin react by thicken the superficial
layer and the effect of UVR will be reduced so we must progress the dose to reach
the same effect.
Doses are progressed as follow:
• E1 is progressed by 25% of the preceding dose
• E2 is progressed by 50% of the preceding dose.
• E3 is progressed by 75% of the preceding dose.
It is unusual to apply doses of intensity E4 to areas of normal skin. E4 is usually
used for the treatment of conditions such as ulcers where slough is present. Whilst
normal skin develops resistance to successive doses of UVR, non-skin areas do not
and it is possible to treat non-skin area with the same dose on successive days to
achieve the same effect.
As UVR provokes an inflammatory reaction in the skin heavy doses
involving large areas can cause systemic illness. The usual guidelines given are:
• E1 may be safely given to the whole body.
• E2 may be applied up to 20% of body surface.
 • E3 may be applied to not more than 4% of body surface area (about
600cm ).2

• E4 may be applied to an area of 25 cm of normal skin, or unlimited

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area of non-skin.

Example:
If E1 is 30s at 450mm, find the second progression (P2E1).

E1= 30s at 450mm

P1E1= E1+ 25% of E1
= 30 + ¼ X 30
= 30 + 7.5 = 37.5
P2E1= P1E1 + 25% P1E1
= 37.5 + ¼ X 37.5
= 37.5 + 9.4 = 46.9s
= 47s at 450mm.

Alteration of intensity with distance

The inverse square low stated that as the distance between the source of
radiation and the patient increases the intensity decreases in proportion to the
square of the distance and this is represent the equation

New time = old time X (new distance) / (old distance)

2 2

That is nt = ot X (nd) / (od) .

2 2

Using the Kromayer, the source of UV is U-shaped burner tube lies 25mm from
the outer window of the treatment head. Thus the patient will always be at least
25mm from the source of UVR. Because this distance is constant, it is not included
in the description of the dose. For example I/C indicates contact of the outer
window with the patient and the distance is 25mm between the patient and source
of UVR, but it must be included in all calculations.

Example:
Using the Kromayer, if E1 is 1s I/C, find E1 at 100mm.

Nt = ot x nd / od
2 2

Nt = x
Ot = 1s
Nd = 100 + 25(constant) = 125mm
Od = 25mm (constant)
 Nt = 1 X (125) / (25)
2 2

= 25s
That if E1 I/C is 1s, the E1 at 100mm is 25s.

Example:
Using the air cooled lamp, if E1 at 900mm is 60s, find the E1 at 450mm.

Nt = ot X nd / od
2 2

Nt = x
Ot = 60s
Nd = 450mm
Od = 900mm
Nt = 60 X (450) / (900)
2 2

= 15s
If E1 at 900mm is 60s, the E1 at 450mm is 15s.

Example:
Using the Kromayer, if E1 I/C is 1s, find the E3 at 100mm.

Step 1: E1 = 1s I/C
E3 = 5X E1 = 5s I/C
Step 2: nt= ot x nd /od
2 2

Nt= X
Ot = 5s
Nd = 25 + 100= 125mm
Od = 25mm
Nt = 5x(125) /(25)
2 2

= 125s at 100mm
E3 at 100mm equals 125s.

Frequency of treatment
The frequency of treatment depends on the level of erythema produced.
Successive doses of UVR must never be given to normal skin while the erythema
producing by the preceding dose is still visible.
The following guide lines should be followed when treating normal skin:
• E1 or MED may given daily.
• E2 given every second day.
• E3 given every third or fourth day (twice weekly).
• E4 may only be given once a week.
N.B.:
When treating non-skin areas such as pressure areas or ulcers, all the doses
may be given daily as there is no erythema reaction.

THERAPEUTIC USES AND INDICATIONS

1- Psoriasis: is a chronic skin disease of unknown cause. The aim of treatment

with UVR is to inhibit DNA synthesis in the cells of the skin and to improve
the skin condition. Courses of whole-body UVB or treatment using
Theraktin with E1 progressed daily or E2 for treatment of small areas three
times per week progressed at each.
2- Acne vulgaris: is a chronic inflammatory condition of the pilosebaceous unit
especially affecting the face, chest and back. The sebaceous glands become
more active at puberty being stimulated by androgens which coupled with
infection by the acne bacillus provokes the formation of blackheads or
comedones. E3 dose may be given to the acne of shoulders and back, E2 is
given to the face, chest and neck. The aims of using UVR are:
a- To produce desquamation to open the blocked pores and hair follicles.
b- Erythema to improve the condition of the skin.
c- Stimulate growth of the healthy epithelium.
d- Antibiotic effect to destroy the infected organisms.
3- Chronic infection: infected areas such as pressure sores and venous ulcers or
any infected open wound are treated with high doses of UVR. The
Kromayer lamp is usually used because it gives a relatively high proportion
of UVC which is notably bacteriocidal. E4 is used to kill surface bacteria.
The aims of treatment are:
a- To destroy and remove the slough (infected materials).
b- Stimulate growth of the granulation tissues.
c- Promote healing by stimulate growth of epithelium.
4- Accelerate healing of uninfected wounds: such as surgical incisions or clean
traumatic skin injuries. E1 or E2 doses of UVR may be used. The aims of
treatment are:
a- Increase the rate of skin growth.
b- Maintain sterility by destroying some surface bacteria.
5- Vitiligo: is a condition in which destruction of melanocytes in local areas
causes white patches to appear on the skin (it is autoimmune disease).
Application of both UVA and UVB to affected areas to induce re-
 pigmentation with protection of the surrounding normally pigmented areas
to avoid darkening color.
6- Counter irritation: UVR may be used for its counter irritant effect in the
relief of pain. E4 dose is given so that the discomfort produce masks of pain
caused by deeper structures.

CONTRAINDICATIONS

1- Dermatological conditions: as acute eczema, dermatitis, herpes simplex and

lupus erythematosus (auto-immune disease).
2- Hypersensitivity to sunlight: people who react adversely to even minimal
exposure to sunlight (photo allergy), febrile disorders (high temperature).
3- Deep X-ray therapy: never apply UVR before three months pass after X-ray
therapy to avoid hypersensitivity.
4- Infrared therapy: if erythema due to IRR is still present this will increase the
effect and absorption of UVR.
5- Tuberculosis or tumors: may be exacerbated by the effect of UVR.
6- Recent skin graft.

DANGERS

1- Shock: the machine should be earthed and the main power cord insulation
intact.
2- Eyes: it is important to protect the eyes of both patient and therapist from
scattered and reflected radiations. The patient should wear goggles even
when not facing the source of radiations. The physiotherapist should be
aware of the cumulative effect of UVR through the day.
3- Over dosage: to avoid long exposure to UVR, use an accurate timing device
especially for periods over about 1 minute. Overlap of doses may lead to
burn.
4- Sensitization: a number of drugs and some foods in few patients can alter the
effect of UVR and cause sensitivity.