A Review of Ultraviolet Radiation Therapy
Summary: Ultraviolet radiation (UVR) has been used for many years
SHEILA S KITCHEN M S ~MCSP DipTP
Senior Lecturer
CECILY J PARTRIDGE PhD FCSP
Reader in Physiotherapy
Centre for Physiotherapy Research, King’s College London
Authors’ note: The purpose of this article is to review the current State
of knowledge about this method of electrotherapy. It has, however. been found
necessary to provide background information to familiarise the reader with
the terms used and the concepts developed and reviewed in the latter part
of the paper
Key words: Review, therapeutic ultraviolet radiation, physiological effects,
hazards, clinical efficacy.
Introduction
THE sun provided the original therapeutic light source, being
advocated by the Greeks more than 3,000 years ago for a
variety of conditions. Its value in the treatment of rickets
was noted in the 18th century and in 1890 Neils Finsen
initiated the use of artificial sources of light in the treatment
of skin disorders. He was awarded the Nobel prize for his
work in 1903. The field has gradually developed from this
point (Anderson et a/, 1984).
In more recent years, therapists have made use of
Part I: Background
UVR is a non-ionising radiation, having a relatively high
photon energy which appears t o lead t o significant and
diverse biological effects (Faber, 1989). It occupies that part
of the electromagnetic spectrum lying between the softest
ionising radiation (soft X-rays) and visible light, and has a
wavelength of between 100 and 380-400 nanometers(nm).
The wavelengths have been’ subdivided into three bands,
depending on the dominant biological effects displayed by
each region.
UV-A 320-400 nm long Black light: will produce
fluorescence in many
substances and may
encourage wound healing
UV-B 290-320 nm middle Skin erythematous region
UV-C 200-290 nm short Germicidal region
The most significant source of UVR is the sun. Both
UV-A and UV-B reach the Earth’s surface, though no rays
of 290 nm or less (UV-C) penetrate the protective layer
surrounding the planet. They are filtered out by the ozone
layer (Lancet, 1978; Faber, 1989).
physiotherapy, June 1991, vol 77, no 6
in the treatment of both skin diseases and wounds. Much work has been
carried out to evaluate its effects in disease. This review considers the
physiological effects, hazards and efficacy of UVR for a variety of skin
conditions.
Biography: Sheila Kitchen qualified as a physiotherapist in 1971. Since
then she has practised clinically and then taught for the last 14 years. She
is now senior lecturer at King’s College London, and is course co-ordinator
for the MSc degree in research methods for remedial therapists being run
at the university. She has undertaken the review of literature in the field of
electrotherapy as part of the research programme of the Centre for
Physiotherapy Research.
Cecily Partridge is a reader in physiotherapy and director of the Centre
for Physiotherapy Research, King’s College London. She worked in clinical
practice for many years but has been in full-time research since 1975. Her
research interests include community physiotherapy, recovery from disability
and the measurement and evaluation of practice in physiotherapy.
ultraviolet radiation (UVR) in the treatment of a variety of
conditions such as psoriasis, acne, alopecia, and infected
and healing wounds.
However, with an increase in use of a wide variety of topical
and systemic substances in association with UVR, therapists
appear t o have relinquished this area of interest and the field
seems t o have been taken over, primarily by dermatologists.
There is an abundance of literature concerning the
l management of dermatological conditions with UVR but little
1 in the area of wound healing.
Ultraviolet radiation obeys the laws that govern all
radiations; they may be reflected, scattered and finally
absorbed by molecular chromophores. UV-B and UV-C are
absorbed primarily in the epidermal layer of the skin. The
degree of absorption is generally greater for shorter
wavelengths (Bruls and van der Leun, 1984), absorption of
radiant energy being a function of wavelength. The result
is that shorter wavelengths penetrate less deeply. Absorption
is affected by the thickness of the epidermis and any
pigmentation of the skin (Anderson and Parrish, 1981;
Faber, 1989). Skin thickening such as in psoriatic lesions will
result in increased scattering and absorption and thus
reduced penetration.
As with all treatments it is important t o describe the details
of dosage. The physical parameters t o be considered when
describing UVR dosage are wavelength, output (watts),
distance from the skin, angle of incidence, time and area
irradiated. The dose t o the patient is described in joules per
square centimetre (J/cm*). The physical characteristics of
the patient must also be taken into account; these include
skin colouring, the nature of the area t o be treated and any
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previous exposure t o UVR. Certain sensitisers may modify
the response of the individual still further (Faber, 1989).
Diffey and Oliver (1981) advise evaluating the dose according
t o the skin erythema as this method takes into account the
individual skin behaviour of patients.
Low (1986) reviews the literature on the quantifying of an
erythema. He describes a list of features commonly used
t o categorise an erythema in terms of ’E’ doses; the
descriptions may vary and the method is subjective but
this is the way normally employed by physiotherapists.
Other methods include the use of colour charts, viewing
the area through colour filters, measuring the reflected light
from the area, and noting vascular changes. Low (1986)
recommends reflection spectro-photometry (described by
Diffey e t a / , 1984) as a reasonable method of determining
the degree of erythema.
The minimal dose which will evoke an erythema (minimal
erythema dose: MED) is regarded as the most reliable
indicator of dosage by Faber (1989) and has been used
extensively by investigators. Low (1986) notes however that
even this may be defined differently by various workers.
Magnus (1976) and Parrish (1982) suggest that an average
dose of 2 0 0 J/m2 at a wavelength of between 2 5 0 and
300 nm will produce a MED on the trunk of a Caucasian
individual w h o has ncit been previously exposed t o UVR.
It is important t o note all the qualifying factors mentioned
by these writers and remember that they may all cause a
variation in the final result.
Most sources of UVR for therapeutic purposes are
artificial; Klaber (19801, Verhagen (1986) and Faber (1989)
list possible sources of radiation. The important differences
between these machines is their variation in wavelength and
output. Diffey (1986) and Diffey and Farr (1987) provide
information on the spectral emissions of a number of
therapeutic lamps; this information is essential in determining
the dose received by a patient as many effects of UVR
appear t o be wavelength dependent. Output will also be
affected by any filters used; Wulf and Erikson (1985) evaluate
a number of UV-A and -B filters (and detectors) and highlight
those which appear most effective in achieving their
objectives.
Physiological Effects
Faber (1989) summarises the underlying reactions in
the tissues which bring about a photochemical reaction.
Electromagnetic energy is converted t o chemical energy
which in turn brings about photobiological processes. Photon
energy is absorbed by chromophores, molecules which
absorb electromagnetic radiation. Examples include melanin,
nucleic acids and proteins (Anderson e t a / , 1984). Upon the
absorption of energy an atom becomes temporarily excited;
it then degrades, releasing energy. This energy may be
released t o further molecules, be involved in a chemical
reaction, or be released as fluorescence of heat. Energy is
therefore made available for a variety of biochemical
processes, those affected being related t o the wavelength
of the original UVR applied (Faber, 1989; Stillwell, 1982).
Both photosensitisation and desensitisation are possible.
A photosensitised reaction results in the photon energy
being absorbed directly by the photosensitiser, examples
being methoxsalen and a variety of proprietary drugs, and
the energy being transferred directly, or via an intermediary
such as oxygen, t o the biochemical compound involved.
The process can also be impeded by ‘quenched such
as vitamin E, carotenes and ascorbic acid (Faber, 1989).
The resulting biochemical reactions include DNA strand
424
breaks and cross links (Edenberg and Hanawalt, 1973;
Lambert, 1976; Kornhauser, 1976) and the production of
pyrimidine dimers (D‘Ambrosio, 1981) and the covalent
dimers of thymidine (Faber, 1989). Photoactivation of
enzymatic activity has also been reported by Southerland
(1977) and D’Ambrosio (19811, though Faber (1989)
states that full agreement on the significance of these
results has not yet been reached.
The immunological system appears to be UV-B sensitive
(Parrish, 1983; Rasanen et a/, 1989; Rivers et a/, 1989).
Contact sensitive reactions are depressed, numbers and
functions of Langerhans cells are mainly reduced - the exact
effect being dose dependent (Mork et a/, 1987; Rivers et
a/, 19891, and changes may occur in the distribution of
circulating lymphocytes (Horkay et a/, 1986; Rivers et a/,
1989). Gollhausen e t a / (1985) noted a suppression of mast
cell mediated whealing, indicating reduced histamine
release, in human skin at a dose of 3 5 J/cm2 UV-A plus
2 0 J/cm2 UV-B. Fjellner and Hagermark (1982) suggested
that this effect could be dose dependent, higher doses
resulting in cytotoxic reactions which could lead to
histamine leakage from mast cells. Immunosuppression
appears t o peak at wavelengths of between 260 and
2 7 0 nm (De Fabo and Noonan, 1983).
Finally, keratinocyte permeability t o the release of
metabolites increases in a dose dependent manner,
suggesting that their cell membranes contribute to the
initiation of the sunburn response (De Leo et a/, 1984);
degeneration of collagen may accompany long-term
exposure to UVR and vitamin D production accompanies
exposure (Holick, 1981).
Skin is the structure most frequently subjected t o UVR.
Faber (1989) notes four gross effects upon it. They are
immediate pigment darkening, possibly due t o the oxidation
of premelanin (Fitzpatrick, 1965; Murphy, 1975; unconfirmed
by Honigsmann, 1986); erythema; the production and
upward migration of melanin granules; and changes in
epidermal cell growth (Faber, 1989).
Hazards
Swanbeck (1984) lists the hazards of UVR as both a short-
term risk of burning (erythema, blistering and pain) and a
long-term risk of actinic elastosis, or wrinkling of the skin,
and carcinogenesis. Faber (1989) expands on these dangers
and adds t o the list the danger of damage t o the eyes,
including photokeratitis, conjunctivitis and possibly some
forms of cataracts; Taylor (1989) evaluates the biological
effects of UV-B on the eye.
Much of the literature concerning the dangers of UVR
discusses the effects of prolonged natural sunlight;,some
of this information may also be of importance in the clinical
environment as cumulative exposure to UVR can be
considered over a number of years. Schothorst e t a / (1985)
demonstrated that long-term psoriatic patients were
subjected to higher UVR exposure levels than outdoor
workers in the Netherlands.
Carcinogenicity has been reviewed by Forbes et a/
(19791, Freidman (19831, van de Leun (1984) and Epstein
(1983, 1990). Therapeutic effectiveness is based on the
ability to inactivate cell division and can therefore result
in altered genetic states in living cells. UV-B wavelengths
are the most harmful, those in the middle of the band
being the most damaging. Van der Leun (1984) showed
that, though there is a relationship between dose and
frequency of carcinoma (Forbes et a / , 19791, low daily
doses produce carcinoma at a lower total cumulative dose
Physiotherapy, June 1991, vol 77,no 6
than. higher less frequent doses.
MacKie etal (1987) compiled a report for the Royal College
of Physicians on the links between natural sunlight and skin
cancer, the types of skin cancer most likely t o occur and
the prognosis and possible precautions which may be taken.
An increase in non-melanoma skin cancer and squamous
cell cancer of the male genitalia of patients treated w i t h
UV-A and psoralen based drugs (PUVA) has been noted;
8-methoxypsoralen is a potent photocarcinogen when
applied to the skin of mice (Urbach, 1974; Young etal, 1982).
PUVA treatment may also exacerbate the effects of previous
exposure t o carcinogens. As PUVA is therefore considered
carcinogenic in the long term, Burns (1989) questions
whether it should be used at all if other effective treatments
are available. Both he and Volden (1986) however, consider
the risks may be worth taking with older patients who do
not respond to other forms of treatment; Burns (1989)
suggests that it may be possible t o minimise problems by
the use of a low dose and minimal exposure area.
The carcinogenic effects of UVR are thought to coincide
w i t h erythematous effects, both being wavelength specific
effects (Green et a / , 19885. A spectrally specific lamp
which minimises erythematous effects may therefore be
helpful in avoiding possible cellular changes. Van Weelden
et a1 (1988) demonstrated that a narrow spectrum lamp
(311 + 2 nm) took longer t o produce tumours in mice
than the conventional broader-band lamp for equivalent
erythematous doses.
Armstrong etal (1985) warns of the difference in spectral
emission of different UV-B lamps. The same MED from
different sources can result in varying erythematous
reactions, possibly leading to over-exposure and severe
sunburn. The spectral emission of devices should therefore
be analysed and particular care should be taken if there is
a change in lamp during a course of treatment. PUVA may
also result in severe erythematous reactions.
Some workers have attempted t o modify severe
erythematous reactions once they have occurred. Stern
Part 11: Clinical Efficacy
UVR is primarily used in the treatment of skin conditions
and extensive work has been undertaken in this area, much
of it involving the use of a combination of adjuvants and
UVR. Ultraviolet radiations may also be used in the treatment
of both clean and infected wounds though much less
literature exists in this area.
Skin Conditions
Psoriasis
This is the skin condition most commonly treated w i t h
UVR and possibly an adjuvant. It is therefore the one
which has been most extensively evaluated.
Treatments primarily consist of the use of UVR alone or
in association with a wide variety of additives, the most
common of which are the tar-based topicals and psoralen
based drugs. More recently, the use of other substances has
been evaluated (Horwitz et a/, 1985; Emtestam etal, 1989;
Gupta e t al, 1989). In 1984, Stern and Anderson e t a l drew
attention to the great variety of methodologies reported in
the literature and the prevalence of deficient data; they
Physiotherapy, June 1991, vol 77,no 6
and Dodson (1985) treated UV-B induced inflammation
with Ibuprofen; relief of symptoms was greater in the group
receiving the drug than in the placebo group, though
clinically the effect was very limited. Therapists frequently
assert that infra-red radiation can be applied t o reduce
the effect of an UVR overdose: a review by Kitchen and
Partridge (1991) found little evidence t o support this,
information being contradictory and incomplete.
Diffey (1989) discusses the possible dangers of UV
radiation to therapists; he notes that some of the most
commonly used lamps emit both UV-B and UV-C, which can
produce harmful acute effects on eyes and skin. Radiation
may not be well contained and hazard exists from both the
direct beam and reflected and scattered rays. The longer-
term risk from UVR rises with frequency of acute symptoms
experienced and the time spent working with UVR. However,
it is low if good practice is followed, acute erythematous
reactions being experienced no more than t w i c e a year.
A number of documents have been published which refer
to the safe use of UVR. They include the International
Commission on Radiological Protection Publication 26
(19771, Environmental Health Criteria (1979) and UV
Radiation: Human exposure to ultraviolet radiation (1986).
Further papers are in preparation by the International
El e c t r o c h e m i c a l C o m m i s s i o n (IEC), C o m m i ss i o n
lnternationale de I'Eclairage (CIE) and, for physiotherapists
specifically, the Chartered Society of Physiotherapy.
Conclusion
Ultraviolet radiation has been used in the treatment of a
number of conditions for a considerable period; its underlying
effects have been studied extensively and information about
the physiological effects of UVR is accumulating. However,
further work is required as there are still areas of uncertainty.
The dangers arising from the use of UVR have also been
evaluated, the extensive and prolonged use of the medium
giving rise t o most problems.
highlighted the further need t o evaluate the effectiveness
of coal tar preparations, dosage parameters, frequency of
maintenance treatment in long-term psoriasis, the optimal
spectral emission for use in this condition and long-term
aspects. Since then further work has been carried out in
these areas and greater attention has been paid t o the
reporting of detail. The aim of treatment is t o achieve
clearance as fast as possible for as long as possible and
thus reduce the total amount of radiation the patient is
subjected t o over the years. Time to recurrence is an
important indicator of success; many treatments clear
psoriasis reasonably well, but relapse may be swift.
Before 1975 there was a feeling that neither UV-A nor
UV-B were effective in treatment of psoriasis (Young, 1972).
Interest in UVR therapy revived w i t h the introduction of
PUVA and resulted in research being directed at a wide
variety of topics in this area.
Psoriasis was found t o respond optimally t o a specific
wavelength within the U V- 6 band; UV-C was of no value.
UV-A was limited in i t s use; Parrish (1977)showed th a t
425
UV-A could be cost-effective at doses of 3 0 0 J/cm2 and a
few workers have evaluated its clinical efficacy. Earle (1980)
and Fisher e t a / (1984) found that it cleared plaques but that
continued treatment was needed t o maintain clearance.
However, the dosage required t o produce results causes
severe erythema, pigmentation and an increased possibility
of melanogenesis, thus suggesting that UV-A alone is an
inappropriate method of treating psoriasis.
Parrish and Jaenicke (1981) demonstrated that psoriasis
responds optimally t o UVR wavelengths of 2 9 0 n m and
above, the most effective being between 3 0 0 and 313 nm;
Fisher e t a/ (1984) confirmed a wavelength of 313 n m as
being optimal. This value falls within the UV-B spectrum.
Van Weelden et a/ (1988) and Green et a/ (1988) demon-
strated that the use of a lamp emitting a narrow band of UV-B
of 311 -t 2 n m was clinically more effective than a broader-
spectrum lamp. Karvonen et a/ (1989) were a little more
cautious, showing that the lamp was at least as effective
as a broad band UV-B lamp; they used it however in
conjunction with tar-based additives. Green e t a l (1988) and
Karvonen e t a / (1989) both noted that the level of erythema
produced at this wavelength was less than that produced
by the broad-spectrum lamp, with the result that Green et
a/ (1988) were able t o treat their patients more frequently.
As a result, time t o clearance was shorter and it was noted
that the remission period was longer.
It also appears that the efficacy of UV-B is dose-
dependent, higher doses resulting in better clearance. Van
Weelden e t a/ (1980) concluded that, using a dose which
produced a slight erythema, IJV-B was as effective as PUVA;
whereas Btenner e t a / (1983), using a lower dose, concluded
that PUVA was more effective.
UV-B of a suitable spectral output and adequate dosage
normally results in between 8 0 % and 90% clearance (Adrian
e t a / , 1980; Kenicer et a/, 1981; Boer e t a/, 1984; van
Weelden e t a / , 1980, 1988; Green e t a / , 1988; Karvonen et
a / , 1989). This treatment is reported to be ineffective most
often when used for the elbows, knees and scalp. Epstein
(1990) noted that the effects of UV-B on psoriasis appear
t o result from the inhibition of DNA synthesis and mitosis
of the hyperproliferating epidemal cells, characteristic of
psoriasis. Direct effects on dermal blood vessels and
infiltrating cells, alterations in the immune system and the
induction of vitamin D production may have a role.
UVR can be supplemented with a variety of topical or
systematic substances. Tar derivatives can act as a sensitiser
t o UV-A but t o be clinically effective doses of radiation in
the range of 30 J/cm2 are required and this results in severe
erythema. Parrish and Jaenicke (1981) suggest that a
combination of tar and UV-B is effective, the result being
cumulative rather than synergistic. Anderson et a/ (19841,
Stern (1984) and Verhagen (1986), in reviews of the
effectiveness of this method, report mixed results and varied
quality in the reports. Some papers, though claiming
success with the method, lack detail of treatment protocols
and thus their contribution t o the discussion of efficacy and
treatment parameters is lessened (Perry et a / , 1978;
Petrozzi e t a / , 1978).
Not all workers have shown tar derivatives t o be effective
adjuncts in the management of psoriasis. Stern e t a / (1986b)
found that the use of tar oil in conjunction with UV-B was
no more effective in treating psoriasis than UV-B and a simple
oil vehicle. This result was disputed by Lowe (1986) and
Dijkstra and Andreano (1987) who believed that the results
were determined by the protocol. Lowe (1983) found tar oil
t o be more effective than an oil vehicle and Dijkstra and
Andreano (1987) tested the hypothesis that the application
-
426
of the topicals immediately prior t o UV-B application might
have impeded the penetration of the radiations. They
confirmed this hypothesis, though Stern thought the effect
likely t o be minimal. Anthralin, which is a tar-based
derivative, was evaluated by Lebwohl e t a l (1985) and Boer
and Smeenk (1986), neither of whom demonstrated a
significant effect as a result of the use of the substance.
Thus it'has not been shown that the use of tar-based
additives together w i t h UVR produces significantly better
results than UVR alone. The method is also expensive,
as it is frequently administered on an in-patient basis, and
is messy t o apply and stains clothing.
These drawbacks t o the use of tar-based treatments have
led t o the extensive use of PUVA, a treatment consisting of
a psoralen-based drug and UV-A. This method was first
reported by Tronnier and Schule (1972) and Parrish et a/
(1974) and evaluated by a large number of workers
(including Klaber, 1980; McMullan, 1981; Williams, 1985;
Volden, 1986 and many others). The drug may be admin-
istered systemically or topically. Psoralens absorb radiation
throughout the UV spectrum w i t h erythematous efficacy
peaking at between 3 3 0 n m and 3 3 5 nm. It is not known
whether this range also reflects the maximum therapeutic
effect, as maximum psoralen sensitivity does not necessarily
reflect maximum therapeutic efficacy.
Voden (1986) summarises the effects of PUVA and
indicates some of the hazards associated w i t h it; thickening
of the epidermis, reduced adhesion between the epidermis
and dermis and delayed erythema can all occur. It has been
commonly accepted that PUVA demonstrates a steep dose-
response curve, which could result in slight dose increases
giving rise to large increases in skin response; this view has
been shown to be invalid (Cox e t a l , 1989). Cellular changes
occur in the epidermis, Langerhans cells are reduced in
numbers, melanocytes proliferate and erythrocyte and
lymphocyte behaviour alters. Mechanisms involved in the
healing process of psoriasis are not clear. Epstein (1990)
suggests that PUVA may modify the psoriatic condition
through its short-term effect of inhibition of DNA synthesis
and cell proliferation, psoriasis being a hyperproliferative
disease. Other possible mechanisms include altered
leucocyte behaviour and immunological activity and effects
on cell metabolic function. Staberg e t a / (1988) demonstrated
that UV-B normalised the levels of vitamin D in psoriatic
patients; this is suggested as a possible mechanism in the
healing process but remains an open question (Epstein,
1990).
Minor side-effects such as lentigines (Jung and Obert,
1986) pruritis (Epstein, 1990) and increased risk of burning
(Klaber, 1980) are noted w i t h this treatment. The major
hazard of PUVA lies in evidence that 8-methoxypsoralen
(8-MOP)and 5-methoxypsoralen (5-MOP)are carcinogenic
in animal models (Urbach, 1974; Young et a / , 1982).
Much work is, however, in progress at present to try
and find alternative, safe sensitisers. lest and Boer (1989)
evaluated acitretin, UV-B, and a combination of the two.
UV-B alone and acitretin plus UV-B were equally effective
in achieving clearance but the combined treatment was
2 0 % faster in achieving 80-100% clearance. Emtestam e t
a/ (1989) tested tin-protoporphyrin and UV-A, the average
cumulative dose of UV-A being 98.3 J/cmZ. Lesions were
improved in all cases and no relapse was seen in a period
of three months. Topically applied corticosteroids were
evaluated in association w i t h either a modified Goeckerman
regimen (Horwitz et a/, 1985) or UV-B (Dover e t a l , 1989).
Following clearance, both groups demonstrated improved
time relapse when compared t o the control groups; Horwitz
Physiotherapy, June 1991, vol77, no 6
e t a l (1985) reported an increase in the time t o relapse from
5.9 weeks t o 17.9 weeks and Dover et a/ (1989) reported
less recurrence of plaques within a six-month period. Gupta
e t a / (1989) conducted a double-blind placebo-controlled trial
on the efficacy of fish oil (containing fatty acids implicated
in psoriasis) and UV-B in 18 patients. The fish oil group
demonstrated significantly less psoriasis at the end of
treatment and this improvement was maintained at four
weeks. Thus a variety of materials appear t o augment the
effects of UVR. Further trials are necessary t o establish more
clearly their efficacy and determine any possible side-effects.
It seems that if all else fails a visit t o the Dead Sea would
provide good clearing in some patients (Abels and Kattan-
Bryon, 1985). The natural minerals and salts of the sea and
sunlight relatively deficient in shortwave UVR are credited
w i t h the success.
Often more than one method of treatment is given;
Morison et a/ (1982), Paul et a/ (19821, and Momtaz and
Parrish (1984) all combined two. Bronner and Morison
(1986) tried a combination of three, using UV-B, PUVA and
methotrexate on ten patients. The results were not good.
A number of side-effects such as tenderness, erythema,
toxicity t o methotrexate and herpes simplex occurred
and the final result was unsatisfactory. Care should be
exercised when combining a number of methods and the
outcome thoroughly monitored.
M o st workers involved in the evaluation of t h e
management of psoriasis over the last ten years describe
their treatment protocol in full and, in general terms, dosage
is similar. Fifty to 8 0 % of the MED is normally used initially;
it is increased according to skin response, usually by between
17% and 4 0 % (LeVine and Parrish, 1980; van Weelden et
a/, 1980; Momtaz and Parrish, 1984) and terminated either
on clearance or possibly after an added period of
'prophylactic' treatment. The length of each individual
treatment and the number of radiations per week vary w i t h
the worker and the skin response of the patient (Van Weelden
e t a / , 1988; Green e t a / , 1988; Karvonen e t a / , 1989). Some
workers, for example Stern e t a / (1986). continue treatment
beyond clearance in order t o attempt t o prolong the period
of remission; they found this t o be effective. Remission
lengths also relate t o the intensity of dosage during
treatment, higher intensities resulting in longer remission.
The total energy dose to clearance for individual patients
is variable, being anything between 6 0 0 and 4,000 J/crnz
(Boer and Smeenk, 1986; Lebwohl et a/, 1985). Some
workers have attempted to find the minimum energy required
to achieve clearance; Kenicer et a/ (1981) compared high
(8 J/cm2) and low (2.4 J/cmZ)intensity radiation in PUVA;
the low-dose radiation was effective for some patients but
others had to be transferred to a high-intensity regimen t o
achieve a result.
Some, but not all, workers describe testing the output of
UVR lamps used t o determine the peak frequency and the
range within which it falls. A measure of dosage received
by the patient should also be made. Fanselow e t a l (1987)
caution that a single measure of the dose delivered by a lamp
in an empty treatment area may not adequately reflect
the dose received by any given anatomical site on the
patient.
DermatitislEczema
Dermatitis and eczema may be considered t o be
fundamentally the same condition. Sjovall and Moller (1985)
reviewed the literature on animal studies in the area of
contact dermatitis and found conflicting results which they
Physiotherapy, June 1991, vol77, no 6
suggested could be attributed t o differences in protocols and
species of animal. Langerhans cells are implicated in contact
dermatitis and may be suppressed by UVR, a view confirmed
by Sjovall and Moller (1985) in a study of allergic contact
dermatitis (ACD) in the rat. Mork and Austrad (1983) report
UV-B t o be effective in local treatment of ACD of the hands;
Sjovall and Christensen (1986) conducted a study t o
determine whether either whole-body solarium UV-A or
suberythematous UV-B could decrease the intensity of
human ACD. In the latter trial, UV-B resulted in suppression
of ACD both in exposed and covered skin, indicating both
a local and systemic effect; UV-A did not demonstrate either
effect. Sjovall and Christensen (1987) confirmed that in
eczema local UV-B was more beneficial t o the patients
than placebo treatment but that, as in the 1987 trial w i th
dermatitis, a combination of local and systemic treatment
was significantly more effective.
Rosen e t a / (1987) evaluated the effect of either PUVA or
UV-B on 3 5 patients w i t h chronic eczematous dermatitis of
the hands. One hand only was treated, the other acting as
a control. The results indicated that PUVA induced complete
clearance of dermatitis in all patients, but nine out of 14 had
relapsed within three months. The UV-B group achieved
significant improvement in the affected hand when
compared w i t h control hands at 12 weeks; the untreated
hands in both groups also showed significant improvement,
again suggesting possible systemic effects. Antigen-specific
suppressor T lymphocytes are associated with the supp-
ression of ACD following UV-B exposure in mice and is both
a local and systemic effect. Thus PUVA and UV-B both bring
about improvement but PUVA was found t o be superior in
its effects.
Falk (1985). Hannuksela e t a / (1985) and Jekler and Larko
(1988) studied atopic dermatitis. Falk (1985) treated 106
patients with atopic dermatitis with either UV-A or UV-A plus
UV-B; he achieved 8 4 % success Lyith UV-A and 9 4 % with
the combined treatment. Relapse in the combined treatment
group was delayed, longer periods of remission occurring.
Jekler and Larko (1988) evaluated UV-B only in treatment
and the doses required. Two different dosage regimens
were tried, starting w i t h either 0.8 or 0.4 MED. Thirteen of
18 patients experienced complete or significant remission
of symptoms in the treated area; only one had significant
remission in the untreated parts. No statistically significant
difference found in improvements results from the different
regimens. This is in contrast to Britton e t a / (19881, w h o note
that patients receiving the greatest doses benefited the
most.
Urticaria
Urticaria is a condition in which there is hypersensitivity
t o a variety of substances, and is characterised by itching
wheals.
Solar urticaria, involving a reaction to natural sunlight, may
be wavelength specific and should be treated as such. It can
be managed w i t h a combination of UV-A and UV-B or UV-B
alone (Harber and Bickers, 1981; Wolska et a/, 1982).
Treatment appears most effective for those w i t h UV-A
spectral problems (Roelandts, 1985). PUVA appears t o
provide a more long-term protection w i t h less need of
top-up treatment but has limitations because of its side-
effects.
Holzle et a/ (19801, Roelandts (19851, and Addo and
Sharma (19871, using PUVA, and Bernhard et a/ (19841,
utilising UV-A, treated sun-induced urticaria1 wheals. All
workers demonstrate an increased tolerance to a number of
427
wavelengths. Details of dosage do vary, possibly reflecting
sensitivity differences in individual patients.
In a randomised double-blind trial Olafsson et a/ (1986)
treated chronic urticaria with either PUVA or UV-A plus
placebo. No statistical difference was seen between the
groups. Hannuksela and Kokkonen (1985) evaluated 15
patients with the same condition, using UV-B for one to three
months. Most were initially better but a gradual relapse
occurred in one-third of cases. Chronic urticaria therefore
appears to respond less favourably t o treatment than does
solar urticaria.
Factitious urticaria (general pruritis and dermographia
secondary t o trauma such as itching) is a difficult condition
t o manage; it was treated by Johnsson et a/ (1987) w i t h
UV-B. Thirty-nine out of 43 patients benefited, though 13
relapsed. These workers felt that the results were promising
and suggest effects on mast cells and their release of
histamine as being possible modes of action.
Other Conditions
Pruritis, pityriasis rosea, pityriasis lichenoides chronica,
pityriasis lichenoides et varioliformis acuta, alopecia,
acne, lupus vulgaris, eosinophilic pustulosis, vitiligo and
polymorphic light eruption have all been treated w i t h UVR
(Epstein, 1990).
The management of pruritis due t o raised bile acid levels
has been reported by Cerio and Low (1987) and Cerio e t a l
(1987), making use of suberythematous, general UVR.
This appeared to temporarily reduce itching and sensitise
patients t o drug treatment. The effect was repeatable but
the mode of action is unknown. Gilchrist et a/ (1977)
previously used suberythematous UV-B successfully to treat
pruritis due t o chronic renal failure. MacKinnon (1986)
reported treating pityriasis lichenoides et varioliformis acuta
w i t h general UVR to the whole body; details of disometry
are lacking. UVR was credited with some success as drug
treatment over the previous six months had had no effect.
A number of authors have reported success treating
polymorphic light eruption with UVR. Gschnait e t a l (19781,
Murphy et a/ (1987) and Addo and Sharma (19871, using
PUVA, and van der Leun and van Weelden (19861, Murphy
e t a/ (1987) and Addo and Sharma (19871, using UV-B,
demonstrated significant improvements in these patients.
PUVA gave rise t o marginally better results than UV-B. Addo
and Sharma (1987) demonstrated that fewer treatments per
week and in total made no difference t o the final outcome
in the group treated with PUVA. Horkay et a/ (1986)
tested the immune system response (blood lymphocyte
populations) of these patients to UV-B and PUVA. A gradual
normalisation of cell ratios was noted w i t h PUVA treated
patients; less pronounced results were obtained with UV-B
treatment, which may reflect the difference in efficacy of
the t w o methods.
PUVA has also been reported t o induce hair regrowth in
some patients suffering from alopecia areata (Claudy and
Gagnaire, 1980; Lassus e t a / , 1980; Mitchell and Douglass,
19851, though this suggestion is not supported by Pestana
e t a / (1987).The latter treated male baldness (types IVa and
Va) w i t h 2% topical minoxidil and either UV-B or PUVA.
Neither caused any increase in the rate of growth beyond
that normally induced by the topical compound alone. Vitiligo
constitutes patches of hypomelanotous skin which may be
treated with 8-methoxypsoralen, phenylalanine, psoralen and
triamcinolone or trimethylpsoralen and UV-A (Cormane er
a / , 1985), Ortel e t a/ (1988) evaluated khellin and UV-A
(KUVA) and found it effective though Duschet et a/ (1989)
428
describe a marked increase in liver transaminases after PUVA
in one patient. UV-B use for patients w i t h psoriasis and
vitiligo resulted in some photoprotection occurring in the
unpigmented areas (Tham e t a/, 1987).
Wound Healing
Therapists have used UVR to treat both clean and infected
wounds for many years. High doses have been used on
infected areas to kill bacteria and lower doses in order to
stimulate the growth of granulation tissue in the wound bed
and increase the circulation to the surrounding area. A limited
number of papers have looked at this area of work.
Experimental Studies
A n experimental study was set up by Basford e t a / (19861,
w h o compared the use of UV-C, 254 nm, w i t h both laser
and occlusion treatment in a porcine model. The lesion was
surgically induced and therefore clean and in healthy tissue.
A dose of 15 seconds was used twice a day until healing
occurred, Basford and his fellow workers claiming that this
was the equivalent of 2 MED in a human subject. There was
no significant advantage seen in any of these treatment
methods when compared w i t h untreated controls, though
the occlusion treated wounds healed slightly faster.
Nordback et a/ (1990) evaluated the effect of UVR on the
healing of experimental wounds in rats and found that,
although there was a slight increase in speed of wound
diminution, the overall time to wound closure was the same
for treated and untreated wounds, the tensile strength for
both groups of lesions, and the levels of inflammation were
the same. No difference was found in terms of bacterial
colonisation of the wounds. They conclude that, though UVR
has some effect on wound healing, it does not appear to
have the clinical effects sometimes claimed for it. Neither
experiment therefore shows any significant benefit from the
use of UVR. It should be noted that the wounds were surgical
and therefore clean and acute and were therefore possibly
in the process of healing at an optimal rate irrespective of
the treatment given.
High and High (1983) conducted an in-vifro evaluation of
the effect of UVR on micro-organisms derived from infected
human ulcers. A standard Kromayer lamp, described as
having an output 254-436 nm, was used t o irradiate the
cultures. The results demonstrated that all organisms tested
were reduced in number by the application of E2, E3 and
E4 doses to varying degrees. None survived an E4 dosage.
High and High (1983) note that extrapolation to ulcers is
complicated by the presence of dead material blocking the
passage of the UVR to the bacteria.
Patients w i t h ulcers exhibit prolonged reduced skin blocd
flow and hypoxia, leading to reduced healing of the lesions
and Dodd et a / (19891 noted that UVR may be used in an
attempt to increase the circulation to the area. They tested
this theory on 12 people, half being controls. A Kromayer
lamp was used to provide a 3 MED to a 2 cni diameter area
of skin in the normal subjects and those with ulcers. The
effects were then evaluated over 15 days. During the first
48 hours both controls and patients exhibited an increase
in transcutaneous partial pressure of oxygen (tcPO,) in the
irradiated areas of tissue when compared with non-irradiated
adjacent areas. The vasoconstrictor reflex associated with
standing in normal non-irradiated tissue was lost during this
period but regained after 48 hours in the irradiated areas.
During days 3-15 the tcPO, was reduced in the irradiated
area when compared w i t h the controls: the vascular
response t o exercise and heating was also reduced. Dodd
Physiotherapy, June 1991, vol 77, no 6
e t a / (1989) list other work which suggests that UVR can
result in reduced blood flow t o tissue upon a variety of stimuli
and suggests that UVR may disrupt the axon reflex and
therefore not assist ulcer healing through the circulatory
mechanisms.
Clinical Studies
Few studies have looked at the efficacy of UVR in the
clinical treatment of ulcers, older accounts being primarily
anecdotal (Fraytes e t a / , 1965; Scott, 1967; Llewellyn and
Lahive, 1965). Doubt has been expressed by some
(Wilkinson, 1968; Frankel, 1980) about the value of this form
of treatment. Rich (1979) and Nordback and Korpi (1981)
evaluated the treatment of crural ulcers w i t h ultraviolet
radiation, using uncontrolled and single case study designs,
and Wills eta/ (1983) conducted what appears to be the first
randomised, placebo controlled trial of ultraviolet in the
treatment of superficial pressure sores. Wills e t a/ (19831,
though including only 16 patients in their trial, were able t o
show that those receiving UVR demonstrated a shorter time
to healing than the control group. This remained so when
age and initial size of pressure sore were taken into account.
The writers note that further work is needed t o confirm these
results and evaluate different treatment parameters.
Burger et a/ (1985) evaluated the bactericidal effects of
UVR, applying a single dose of UVR at an intensity of E 4
to ulcers irrespective of level or type of infection and the
amount of dead tissue in the area. Single swabs were taken
both before and immediately after treatment. Under these
conditions the bactericidal effect appeared t o be organism-
specific; some were totally destroyed, some reduced and a
few remained unaffected.
Further studies are needed in this area t o determine the
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Ultraviolet radiation has a long history of u5e in the
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ACKNOWLEDGMENTS
We would like t o thank the Department of Health for funding this
work. Particular thanks also go t o Dr Brian Diffey, Regional Medical
Physics Department, Dryburn Hospital, Durham, and John Low,
School of Physiotherapy, Guy's Hospital, London, fortheir invaluable
comments along the way.

booklets and leaflets @/

Top t o Toe Team, published by South East
Kent Health Promotion Unit, 5 Town Walk,
Folkestone, Kent. 11 pages.
Intended for those involved in personal,
social and health education, or the devel-
opment of related policies in Kent, this
booklet lists helpful resources starting w i t h
a list of contacts in each subject area. It then
charts the aims and activities in each subject
- such as 'Dental health' or 'Body and
postural awareness', for each age group
within schools. The contacts and resources
are specific t o Kent, but the attractive and
easily appreciated format could be copied
in any administrative area.
US Foundation Support in Europe, edited by
Kerry Robinson. Published by and available
from the Directory of Social Change, Radius
Works, Back Lane, London NW3 lHL, May
1991 (ISBN 0 907164 5 2 8). €12.50 plus
€1.50 postage prepaid orders.
American foundations give about $ 2 5
million a year to European charities, of which
about half comes t o Great Britain. This
directory lists almost 100 foundations which
have made grants for work in Europe.
Information is given on financial data,
funding policy, background, application
guide lines, and examples of past grants.
While of particular interest t o organisations
w i t h an international bias t o their work, this
unique guide will help a full range of charities
and voluntary groups t o extend their fund-
raising programmes across the Atlantic.
Equipment for Disability - A guide t o
provision, compiled by Michael Mandelstam.
Published by the Disabled Living Foundation.
Funded and supported by the Nuffield
Provincial Hospitals Trust, April 1991 (ISBN
0 901908 5 4 1). 4 0 pages. Available from
Haigh and Hochland, International bniversity
Booksellers, The Precinct Centre, Oxford
Road, Manchester M13 9QA. € 2 including
postage, discounts for quantities.
A short guide t o the complex and
confusing system of equipment provision for
people w i t h disabilities of all ages in the
United Kingdon. The booklet covers many
types of equipment and home adaptation,
from incontinence pads t o environmental
controls, from hearing aids t o bathrooms.
Each main category of equipment is
explained by a flow chart and a short text.
The equipment index allows the reader t o
look u p specific equipment and be referred
t o likely channels of provision. For quick
reference by busy professionals, a loose
fold-out (wall) chart, which summarises
the contents of the booklet, is enclosed.
It should be helpful t o a wide range of
policy makers and professionals working
in health and social services.
Self-help Groups: A way t o health; devel-
oping partnerships between self-help groups
and health promoters. Published by and
available from the National Self-help Support
Centre, 2 6 Bedford Square, London WC1B
3HU, December 1990 (ISBN 0 7199 1308
X). € 4 . 5 0 including postage.
Based on a discussion generated at a
seminar funded by the Health Education
Authority, this report focuses on the roles
health promoters and self-help group
members can take on in the life of a self-help
group, and the implications for policy and
practice.
These issues are summarised in a set of
guide lines for good practice and illustrated
by examples of existing partnerships.
The Misbehaving Bladder: Self-help for a
common problem, published by the Health
Promotion Research Trust, 49-53 Regent
Street, Cambridge CB2 lAB, 1990. 12 pages
fold-out.
Apparently aimed at older people, this
entertainingly illustrated leaflet is instructive
about the urinary system and adopts a
positive approach to overcoming bladder
problems. It includes a plan of management,
a check list and a record chart, and would
be useful t o hand t o patients, not least to
cheer them up.

432 physiotherapy, June 1991, vol77, no 6