Ultraviolet Rays
Mr. Hariraja M
Lecturer
Lecture Outline
2

This lecture deals about the topic UVR in following subcategories;
1. Basics principles & production of UVR
2. Indications & Contraindications of UVR
3. Physiological & Therapeutic effects of UVR
4. Methods of application / Treatment procedure – An
overview of clinical application
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Lecture Objective
3

At the end of this lecture, the students will be able to;
1. Recall the principles & production of UVR.
2. Compare & list down some of the indications,
contraindications, precautions, physiological, therapeutic
effects, advantages, disadvantages & dangers of UVR,
Determination of MED, Calculation & Progression of dosage.
3. Safely & effectively to demonstrate the testing of machine,
methods of application to various segments of the body as a
treatment.
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Introduction
4
Ultraviolet radiation (UVR) covers a small part of
electromagnetic spectrum lying between the violet end of the
visible light and X-ray region with a frequency of 7.5x1014 to
1015 and wavelength 400 nm to below 280 nm
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Introduction
5

The radiations introduced to the tissues through
subcutaneous tissue, hair follicles, and sebaceous
glands.
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Classification of UVR
6
N. B
Vacuum UV is radiation of wavelength between 200-100 nm it is rapidly
absorbed in air.
UVA
400-315
nm (long
UV).
It is non
ionizing
and
produce
fluorescen
ce in many
substances
UVB
320-290
nm
(medium
UV).
It is non
ionizing
and
produce
skin
erythem
a
UVC
290-200
nm (short
UV).
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It is
ionizing
and has
germici
dal
effects.
Classification of UVR
7
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Production of UVR
8

The natural source of ultraviolet radiation is the sun.
We must protect our eyes from bad effects of
Ultraviolet radiations.
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Production of UVR
9

The therapeutic UVR are produced by
mercury vapour lamp 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
burner tube. The current is applied to the
electrodes, the mercury vapour and the
passage of electrons through the vapour
establishes the UVR.
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Production of UVR
10

All UV lamps produce visible light and infrared rays heat the burner
from 60C to several hundred degrees, it is therefore 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 circulation with fan), and water
cooling (using a water jacket surrounding the burner with continually
circulating water).
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Ultra-Violet lamps
11

1.
2.

Mercury vapour lamp
Air cooled medium pressure mercury lamp
Water cooled mercury vapour lamp (kromayer
lamp)
Fluorescent tubes
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Air cooled medium pressure mercury lamp
(Hanovia Alpine sun lamp)
12


It is U shaped tube made of quartz
Used in treatment of GENERALISED SKIN
CONDITIONS AS ACNE AND PSORIASIS.
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TRIDYMITE FORMATION
13



The heat produced inside the Burner or Quartz tube
causes some of it to change to another form of silica
called TRIDYMITE.
Tridymite is OPAQUE to UVR. So output of the rays
tends to FALL.
So after every 1000 hrs of exposure of UV
radiations, it is recommended to change the quartz
tube.
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Water cooled mercury vapour lamp (kromayer
lamp)
14



It is designed to be used in contact with the tissues ,
both on the skin surface and inside body cavity.
The emitting tube is enclosing of water jacket which
cool it and filtered out the infrared to avoid burn.
Used for treating localised lesions as pressure areas,
ulcers, and sinuses in open areas.
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15
CARE OF MERCURY VAPOR LAMP
(Air & Water cooled)






It must be kept dry.
It should not be turned on & off more frequently.
After 1000hrs of use the burner must be renewed.
The burner of an air cooled lamp should be cleaned
regularly with absolute alcohol.
The burner should not be touched with fingers.
After every 8hrs of use the distilled water should be
renewed.
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ADVANTAGE & DISADVANTAGE OF MERCURY
VAPOR LAMP
16


It used for GENERAL UV IRRADIATION.
The spectrum contains a large proportion of short
UVR which are undesirable for the general
treatment.
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Fluorescent lamps
17

They are commonly used for generalized irradiation
as in Theraktin tunnel or PUVA.

The output of the tube can be partly UVB and
partly UVA 280-400 nm or totally UVA 360-400
nm

Each tube is about 120 cm long
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Fluorescent lamps
18
Theraktin lamp consists of a four fluorescent tubes incorporated
into a semi-circular tunnel. Fluorescent with a spectrum of 280-400 nm
•
A narrow band fluorescent was developed with a wavelength of
around 311 nm.
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Psoralen + UVA (PUVA) PUVA Lamp
19

It is used in the for the treatment of psoriasis
where a large amount of UVA is required

Fluorescent tubes are used with certain type as
the phosphorus coating is different which lead to
emission of UVR in the spectrum from 315-400
nm.
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PUVA Apparatus
20

A number of tubes (48) are fixed in the walls of a treatment
cabinet in which the patient stands.

This treatment is conduct two hours after patient has taken a
photoactive drug as psoralen.

The length of the exposure depends on the DEGREE of the
patient's pigmentation. Accordingly, the darker the patient, the
longer the exposure time.
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Factors affecting the extent of reaction
21
1.
2.
UV wavelength
The amount of UV absorbed.
PENETRATION OF THE UV rays


UVA – Dermis level.
UVB – Deep Epidermis
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Physiological effects
22
Immediate
acute effects
The immediate
acute effects
of UV on eye
Long term
chronic effects
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PHYSIOLOGICAL EFFECTS OF UVR –
Local effects
23
1-Erythema

Erythema is reddening of the skin as a result of an inflammatory
reaction stimulated by ultraviolet rays→ release of histamine-like
substance and prostaglandin→ dilatation of the capillaries and
arterioles and exudation of fluid into skin.
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1-Erythema
24

Erythema increase with the increase in wavelength of
UVR. (Directly Proportional)

There are four degree of erythema see 464

The latent period needed for erythema to appear from
2-4 h

High exposure lead to edema and blister formation
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PHYSIOLOGICAL EFFECTS OF UVR
25


1.
2.
2- Pigmentation
Pigmentation or tanning of the skin follows the
erythema, its amount varies with the intensity of the
erythema. It is formed 2 days after exposure
Causes :
Formation of melanin in the deeper layers of the
epidermis
Migration of the melanin
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26
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27
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PHYSIOLOGICAL EFFECTS OF UVR
28
3- Thickening of the epidermis




UVR lead to increased keratinocyte cell turnover in the
basal layer of epidermis, there by causing thickening
of the skin.
Both pigmentation and thickening provide protective
action to UV that lost in 4-6w.
As thickening reduce penetration, longer doses are
required to repeat an ERYTHEMAL reaction.
E125%, E2 50%, E3 75%,with no progression of E4
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29
PHYSIOLOGICAL EFFECTS OF
UVR
4. Desquamation / peeling
 It is the CASTING OFF of dead cells from the surface
of the skin.


The desquamation is proportional to the intensity of the
erythema.
The peeling results in REDUCTION / LOSS OF THE
INCREASED RESISTANCE TO THE RAYS.
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PHYSIOLOGICAL EFFECTS OF UVR
30

5- Antibiotic effects
Destructive effects of ultraviolet radiation include
the destruction of viruses, bacteria, and other small
organisms on the skin surface
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PHYSIOLOGICAL EFFECTS OF UVR General
31

6 - Formation of vitamin D
Is accelerated by UVR, vitamin D is required to assist
in the absorption of calcium and phosphorous from
the intestine to blood stream. As UVB is able to
convert sterols in the skin as 7-dehydrocholesterol to
vitamin D
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PHYSIOLOGICAL EFFECTS OF UVR
32
7 - immunosuppressive effects



UVR trigger immunosuppressive effects both local
and systemically
UVB destroys Langerhans cells and stimulate the
proliferation of suppressor T cells that inhibit
antibody production
This effect contribute to the development of cancer.
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The immediate acute effects of UVR on the eyes
33

Strong doses of UVB produce conjunctivitis,
photokeratitis , this lead to eye irritation ,watering
and photophobia.

While UVB is absorbed in the cornea, UVA can pass
to be absorbed in the lens of the eye.
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Long term chronic effects of UV on the skin
34



1 . Cancer
Exposure to UV many years increase risk of skin
cancer, basal cell and squamous cell carcinomas.
2. Solar elastosis and aging
Prolonged exposure lead to premature aging of the
skin
The skin become wrinkled, dry and leathery,
decrease function of sebaceous and sweet gland
with loss of elastic tissue.
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Therapeutic effects and uses
35
Psoriasis
Acne vulgaris
Eczema
Chronic
infection
Vitiligo
Treatment of
vitamin D
deficiency
Protection of
hypersensitive
skin
Hypertension
Pruritus
Psychological
benefits
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Therapeutic effects and uses
36
Treatment of Psoriasis


Application of UVR is it help to decrease DNA
synthesis.
Types of treatment regimens:
The Goeckerman regimen
Leeds or Ingram regimen
PUVA
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Therapeutic effects and uses
37
Treatment of Acne valgaris


1.
2.
3.
4.
E2 is used to cause peeling or desquamation .
The effects include:
Acceleration of skin growth.
Production of non specific inflammatory response
control infection
Sterilization of the skin surface
Hides the papules by forming pigments
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Therapeutic effects and uses
38
Treatment of Chronic infection

High dose UVR is effective in treatment of infected open
wound. E3 dose is sufficient, the dose may be given daily.

The aim of UVR irradiation is to destroy the surface
bacteria, remove the (SLOUGH) infected material &
promote repair.
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Therapeutic effects and uses
39
Eczema is an INFLAMMATORY RESPONSE in the skin associated with
OEDEMA. The patient suffers marked ITCHING with REDNESS,
SCALING, VESCILES & exudation of serum on the skin.
Treatment of Eczema
 Mild doses of UVR
Treatment of Vitiligo
 It is a condition in which destruction of MELANOCYTES in local
areas causes WHITE PATCHES to appear on the skin.
 Both UVA and UVB stimulate the activity of melanocytes.
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Therapeutic effects and uses
40
Treatment of vitamin D deficiency

UVR can be used in cases of rickets, osteomalacia, and senile
osteoporosis
Protection for hypersensitive skin
 UVR reduces the effects of sun burn
Hypertension

UVR help in reduction of blood pressure when the whole body
is irradiated.
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Therapeutic effects and uses
41
Pruritis

Application of UVB alone or with combination of
cholestyramine.
Psychological benefits

As the patient feel better by the tanning of the skin
giving a better look
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Contraindications
42
Irradiation of the eyes
• It causes damage to the cornea.
• Patient should wear opaque goggles during treatment.
Skin cancer
• As it is carcinogenic
Pulmonary tuberculosis
• As it is exacerbated by exposure to UVR
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Contraindications
43
Cardiac, kidney, and liver disease
• As it is harmful
Systemic lupus erythematosus
• As it aggravated by UVR
Fever
• It is general contraindicated
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Precaution to the use of UVR
44
Patient taking
• As this medication increase the sensitivity to UVR
photosensitizing medication
resulting to risk of burn with high dose.
Photosensitivity
Recent X –ray therapy
Until the effect of the prior
dose have disappear
• As it exaggerate response to UVR
• As prone to develop malignancy
• To minimize the risk of burn
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Danger of UVR
45
BURN
• Careful determination of the MED
• Avoid repeating exposure
PREMATURE SKIN AGING
• Due Chronic exposure
• Skin will be dry, coarse and leathery with wrinkling and abnormal pigmentation
• This can be avoided by limiting exposure to UVR
CARCINOGENESIS
• Basal ,squamous cell carcinoma and malignant melanomas
• UVB isless common
• PUVA is more carcinogenic
Damage to eye
• Patient therapist and should wear black glasses
• Patient should wear protective goggles for12 h following the psoralen.
Adverse effect due to PUVA
• As short term nausea, vomiting that persist 1-4 h after ingestion of psoralen
• Prolonged, high dose lead to skin damage, non malignant lesion, squamous cell
carcinoma
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Test dose & determinig med



46
It is used to assess the individual patients (ERYTHEMAL)
reaction to uvr irradiation.
The basis for any calculation of any UVR dosage is the
MED (MINIMAL ERYTHEMAL DOSE)
A minimal dose (MED) is the length of the ultraviolet
exposure required to produce a mild erythema, which
appears within 6 to 8 hours and still just visible after 24
hours.
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Test dose cont….







47
The patient must understand that the purpose of the MED test is
to DETERMINE just how much EXPOSURE TIME is necessary
based on their skin sensitivity.
Proper patient education should be given:1. Wear Goggles
2. Observe & monitor the skin condition
3. Keep skin moisture following exposure to UVR
4. Pigmentation changes are to be expected & are a normal
response.
5. Prolonged & repeated exposure leads to premature aging.
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How to determine the MED / skin test
48






1. The area chosen for the test is of importance.
2. Because the patient is to inspect at regular intervals
a convenient, visible site is essential.
3. It should be clear of skin disease.
4. The FLEXOR SURFACE of the FOREARM is the most
usual site.(Other sites are – Abdomen, Medial aspect of
arm / thigh)
5. The selected site should be cleaned with soap &
water to remove surface grease.
6. Cover the patient other areas leaving only the
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forearm exposed to UVR.
How to determine the MED of UV
49

7. Three to Five holes of at least 2cm² & 1cm apart are
cut in a piece of lint/paper/cardboard is taken for
irradiation of UVR along with a slide cover – to pull up to
reveal one opening at a time.
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How to determine the MED of UV
50
8. This cutting is fixed to the forearm with adhesive plaster.
9. The cuttings are of different sizes & shapes in-order to
make IDENTIFICATION OF THE ERYTHEMA EASIER for the
patient.
10. Allow the lamp to warm up according to the manufacturer
instructions.
11. Place the lamp PERPENDICULAR to the area being
tested (Forearm) & a DISTANCE of 60 to 90cms from the site.
12. Expose the 1st opening for 30sec, then expose the
2nd opening for another 30sec & go on till the last
opening
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How to determine the MED of UV
51
13. So the 1st opening would receive the longest exposure
time & the last opening would receive the least amount of
exposure time.
14. Switch off the lamp
15. Instruct the patient to MONITOR the forearm every 2hrs
& note which opening or shape appeared pink / red first &
when it faded / disappeared.
16. The patient is also given a card similar to the opening to
make a note.
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Description of degrees of erythema
Degree of
Erythema
52
Latent
period
In HRS
Appearance
color
Duration
of
Erythema
Skin
Oedema
Skin
discomfort
Desquam
ation of
skin
Relation to
E1 Dose
E1
6-8
Mildly pink
<24hrs
None
None
None
E1
E2
4-6
Definite
Pink Red.
Blanches on
Pressure
2 Days
None
Slight
Soreness,
Irritation
Powdery
2.5% of
E1
E3
2-4
Very red,
Does not
blanch on
pressure
3-5 Days Some
Hot &
Painful
In thin
Sheets
5% of
E1
E4
<2
Angry Red
A Week
Very
Painful
Thick
Sheets
10% of
E1
Blister
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dosage


a)
b)
c)
d)

53
The skin response to UVR depends on;
1. The quantity of UVR energy applied to unit area of
the skin.(Depends on);
The output of lamp – Make, Type, Aging
Distance between the lamp & the skin – Inverse square
law
Angle at which radiations fall on the skin – cosine law
Time for which radiations are applied
2. The sensitivity of the skin
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CALCULATION OF DOSAGE
54


E1 is the basic of UV calculation which is
determined for each individual patient by
performing a skin test. From this point all other
doses of UVR can be calculated.
The two significant units of measurement are:
The length of time (seconds).
 The distance from the source of UVR to the patient
(millimetres).

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CALCULATION OF DOSAGE
55

E1 is determined from the skin test, the E2, E3 and
E4 are calculated using the formulas:

E2 = 2½ x E1

E3 = 5 x E1

E4 = 10 x E1
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CALCULATION OF DOSAGE


56
EXAMPLE:
If the E1 dose of the patient is 25sec, calculate the
E3 dose?

E1 dose = 25sec

E3 dose = 5 x E1

E3 dose = 5 x 25 = 125sec
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PROGRESSION OF DOSAGE OF ULTRAVIOLET RAYS
57




Because ultraviolet, when applied to normal skin, causes
reactions which thicken the superficial layers, each dose
must be progressed in specific way to reach the same
effective level of ultraviolet at each treatment. Doses are
progressed as follows:
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
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PROGRESSION OF DOSAGE OF ULTRAVIOLET RAYS
58

It is unusual to apply doses of the intensity of an E4 to areas
of normal skin. A dose of this intensity is usually used for the
treatment of conditions such as ulcers where slough is
present. Whilst normal skin develops a resistance to
successive doses of UV, non-skin areas do not, and it is
possible to treat an area not covered by skin with the same
dose on successive days to achieve the same result.
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Examples of progression of dosage
59

Examples of progression of dosage





If E1 is 30s, find the second progression (P2E1)?
E1= 30s
P1E1 = E1 + 25% of E1 = 30 +30/4 = 30 + 7.5
=37.5s
P2E1 = P1E1 + 25% of P1E1 = 37.5 +37.5/4 =
46.9s
P2E1 = 47s.
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Alteration of the intensity with distance
60
•
•
•
•
•
The law of inverse square state that: as distance
between the source and the patient increases the
intensity decreases in proportion to the square of the
distance and this is represented in the equation:
New time = old time X (new distance)2
(old distance)2
that is nt = ot X (nd)2
(od)2
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Alteration of the intensity with distance
61
•
•
Using the Kromayer lamp, the source of UV is Ushaped burner lies 25mm from the window of the
treatment head. Thus the patient will always be at
least 25mm from the surface of UVR. Because this
distance is a constant, it is not included in the
description of the dose.
For example: the expression I/C indicates contact of
the outer window with the patient and a distance
therefore of 25mm between the patient and the source
of UV, but it must be included in all calculations.
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Alteration of the intensity with distance
62
•
•
•
•
•
•
•
•
•
•
•
•
Example
Using the Kromayer, if the E1 of the patient is 1s I/C, find the E1
at 100mm?
Nt = Ot X (nd)2
(od)2
Nt = X
Ot = 1s
Nd = 100 + 25 (constant distance) = 125 mm
Od = 25 mm
X = (1)2 X (125)2
(25)2
= 25s
That if E1 I/C is 1s, the E1 at 100mm is 25s.
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Alteration of the intensity with
distance
63
•
•
•
•
•
•
•
•
•
•
•
Example
Using air-cooled lamp, the distance is measured from the burner of
the lamp to the patient.
Using the air cooled lamp, if the E1 at 900mm is 60s, find the E1 at
450mm?
Nt = ot X nd2/ od2
Nt = ?
Ot = 60s
Nd = 450mm
Od = 900mm
Nt = 60 X (450)2 / (900)2
= 15s
If the E1 at 900mm is 60s, the E1 at 450mm is 15s.
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Alteration of the intensity with
distance
64
Example
• Using the Kromayer, if the E1 I/C is 1s, find the E3 at
100mm.
• Step 1:
E1 = 1s I/C
•
E3 = 5 X E1 = 5s I/C
2
2
• Step 2: nt = ot X nd /od
•
Nt = ?
•
Ot = 5s
•
Nd = 25 + 100 = 125mm
•
Od =25mm
•
Nt = 5 X (125)2/ (25)2 = 125s
•
E3 at 100mm = 125s
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Selection of dosage
65


The dosage level is selected according to the effects required for
the treatment of the presenting condition.
The following guide lines should be followed:
1- E1 or MED may be given to the total body area.
2- E2 may be only be given to up to 20% of the total
body area.
3- E3 may be only given to up to 250cm2 of normal skin.
4- E4 may only be given to an area of up to 25cm2 of normal skin,
but it is usually only given to non-skin areas where the size of the
area is not important.
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Frequency of Treatment
66
•
•
•
•
•
•
•
The frequency of treatment depends on the level of erythema
produced. Successive doses of ultraviolet must never be given
to normal skin while the erythema produced by preceding
dose is still visible.
The following guide lines should be followed when treating
normal skin:
E1 or MED may be given daily.
E2 should be given every second day.
E3 should be given every third or forth day (twice weekly).
E4 may be only given once a week.
N.B. when treating non-skin areas such as pressure areas or
ulcers, all doses may be given daily as there is no erythema
reaction produced.
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Heliotherapy
67


It is the lower UVB spectrum of the sun and the higher
UVA spectrum that produce the benefit without skin
damage.
It is the treatment by natural sunlight which used
primarily for psoriasis

It also used for treatment of cutaneous tuberculosis

It is not used now.
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