chapter 13. ultraviolet radiationcontents.kocw.net/kocw/document/2014/cu/shinhwakyung/8.pdf ·...
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CHAPTER 13. ULTRAVIOLET RADIATION
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Figure 12-06. The electromagnetic spectrum ranges from low frequencies in the hertz range to over 1023 Hz, with wavelengths varying from over 10,000 km to less than 1 pm.
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Physical properties of UV radiation
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Figure 13-01. Bands of ultraviolet (UV) radiation. ELF, Extremely low frequency; IR, infrared.
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Physical properties of UV radiation5
Electromagnetic radiation with a frequency range of 7. 5 x 1014 to over 1015 Hz wave length from 400nm ~ 290nm between X-ray and visible light
3 bands UVA (320 ~ 400 nm) : long wave UV, fluorescence (형광 생성) UVB (290 ~ 320 nm) : middle wave UV, erythema (홍반 생성) UVC ( < 290 nm) : short wave UV, germicidal (살균)
※ physical effects by non-thermal mechanism
Most significant source of UV → by Sun UVA, UVB : reach the earth ` UVC : filter out by ozone layer
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Factor influenced on physiological effects of UV Wave length of the radiation intensity of radiation reaching the skin depth of penetration
high intensity of UV radiation reaching the patient’s skin
high power lamp close to the patientperpendicular to the surface of the skin
Deepest penetration of UV
- highest intensity - longer wavelength - lowest frequency - UVA : several milimeters of skin
But UVB, UVC : less deeply and are almost entirely absorbed in
the superficial epidermal layer
Physical properties of UV radiation6
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Snell의 굴절 법칙
개요. 광선 및 전파가 서로 다른 매질의 경계면을 입사하여 통과할 때 입사각과 굴절각의 관계식
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Lambert의 흡수의 법칙
빛의 세기가 I인 빛이 두께가 d 인 물질층을 통과할 때 빛의 흡수로 인한 투과하는빛의 세기의 감소에 관한 관계
log (I0/I) = μd
입사광의 세기 I0투과광의 세기 I 흡수층의 두께 d 흡수계수(농도) μ
물질의 두께가 두껍고, 흡수계수가 큰 물질일수록 투과되는 광선이 적다→ 광선치료 시 여과기filter)를 선택할 경우 흡수계수와 두께를 고려할 것
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Lambert’s cosine law
광원과 물체가 이루는 각도에 따라 광선의 세기는 달라진다
법선과 입사광선 사이에 존재하는 각 Θ가 있다면
빛의 세기 (반사되지 않고 투과되는 빛 에너지)는 cos Θ값에 비례한다.
→ cosine 각이 클수록 효율(cos Θ)은 적어진다.
∴ 광원과 환자의 표면이 이루는 각이 90°(cos 0 °=1)로 갈수록
효율은 커진다.
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거리 제곱 반비례의 법칙(inverse square law)
t1/ d12 = t2/d2
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광원에서 나온 빛은 한 방향으로 직진하는 것이 아니라, 사방으로 퍼지기 때문에 광원에서 물체까지가 거리가 멀수록 광선의 효율은 떨어지게 된다.
예) 광선복사를 20 cm에서 60 초로 노출했다면, 10 ㎝의 거리에서는 몇 초 동안 노출해야
처음의 강도와 같을 것인가?
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Effects of UV radiation
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Effects of UV radiation 12
skin absorption of electromagnetic energy → photobiological process
Skin erythema
Tanning
Epidermal hyperplasia
Vitamin D synthesis
Bactericidal effects (살균 작용)
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Erythema production 13
A result of dilation of the superficial blood cell caused by the release of histamine
UVB exposure or UVA exposure after drug sensitization
Mechanism of UV-induced erythema Prostaglandin release from epidermis DNA-damaging effects of UV radiation
Symptom of severe erythma- blistering(물집), tissue burning, pain, risk of cell damage
Minimal erythemal dose (MED) : smallest dose of UV to produce erythemawithin 8 hrs → within 24 hrs
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홍반 반응의 측정 2400 ~ 3200 Å
홍반하 용량 (Suberythema dose)
최소 홍반 용량 (minimal erythema dose, MED), 1도 홍반 용량, 강장 용량(tonic dose)
2도 홍반 용량 (2nd erythema dose) : 경미한 sunburn reaction
3도 홍반 용량 (3rd erythema dose) : 반대자극 용량 (counter irritant dose)
4도 홍반 용량 (4th erythma dose) : 파괴 용량(destructive dose)
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홍반 2400 ~ 3200 Å
정도 반응 출현 시간 시각 반응 지속시간 검사
1도 Minimal erythemaTonic effect
6~8 시간 약간 붉은색 24~36시간 검사전신치료
2도 경미한 sunburn 4~6시간 붉은색 2~3일 전신치료국소치료
3도 Counter irritation 3~4시간 붉은색, 부종 1주일 국소치료
4도 destructive effect 2시간 강한 발적,물집, 괴사
수주일 국소치료
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Tanning 16
Delayed pigmentation of the skin by UV exposure
Mechanism of tanning
↑ production and upward migration of melanin granules
↑ oxidation of premelanin in the skin
∴ ↓ the penetration of UV to deeper tissue layers
protective response of the body
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색소 침착 2800 ~ 3300 Å
2800 ~3300 Å 광선이 기저세포층에 흡수 → 멜라닌 아세포에 의해 tyrosine이 melanin 으로 전환된다.
(tanning effect )
: 색소 침착은 피부암에 대한 방어 작용
★ 3100 Å 이하 : 세포 구조의 변화, 멜라닌 색소 형성 인자의 자극
3100 ~ 4200 Å: 표면 멜라닌의 흑화 현상(darkening)
태양, 탄소 방전등 : 갈색의 색소침작
수은 증기등 : 회색의 색소 침착
색소 침착의 기전
- UVA (즉각적인 표피 천부로 멜라닌 이동), UVB(2~3일, 지연적)
- 스트레스
- 내분비 기능 장애 ex) 부신, 간 기능 저하
Tanning effect
- 3000~4400 Å ( 3400 Å에서 최대)
2540 Å : 2~3주 지속, 2970 Å : 1~5개월 지속
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Epidermal hyperplasia18
Thickening of the superficial layer of the skin - occurs a approximately 72 hours after exposure to UV radiation - by repeated exposure
Mechanism↑release of prostaglandin precursors leading to increased DNA synthesis
by epidermal cells ↑epithelial cell turnover and cellular hyperplasia
Most UVB exposure Protective response to UV exposure Progressive higher doses of UV radiation are generally need during a course
of UV Tx
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Vitamin D synthesis 19
Conversion of ingested provitamin D to active vitamin D
Vitatmin D
- essential vitamin for bone formation
( ∵ control of calcium absorption)
- brain, kidney, intestine, endocrine, immune, and cellular function
Deficiency of Vitamine D
- poor intestinal absorption of calcium
- if severe, rickets ( by failure of bone mineralization)
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Figure 13-04. Conversion of provitamin D to active vitamin D andsome of the physiologic roles of vitamin D.
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비타민 D3의 형성, 항구루병 효과 3200 Å 이하
자외선은 피부의 상층, 모낭, 피지선과 땀샘에 있는
plant sterol, ergosterol, 7-hydro cholesterol 등에 흡수되어 부산물로 Vt D 합성
Vt D 생성
3200 Å 이하 , 2830 Å 에서 최대
( Stillwell : 2400 ~ 3000 Å , Scott : 2700~ 3100 Å)
비타민 D3의 활성화
2700~ 3000 Å
비타민 D 기능
- 칼슘과 인의 흡수를 촉진, 조직 중의 인산을 칼슘과 결합시켜 뼈에 침착
- 조직 중의 칼슘 축적을 조정하는 부갑상선의 기능을 원만하게 함
- 구루병, 충치, 골절 예방
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Bactericidal effects 22
UVC in adequate dose
Standard hospital cleaners, open wound, wound healing
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살균 효과 2900 Å 이하 (abiotic ray)
2400 Å에서 최저 살균 효과
2652 Å 에서 최대 살균 효과 ( 2537 Å : 90% 살균 효과)
※ 만성궤양, 욕창 : 2537 Å
3000 Å 이상에서는 살균 효과 적음
기전
광선 (2900 Å 이하)의 흡수에 의한 핵산 파괴에 의함 (abiotic ray )
→ 표피의 천층에서 흡수되어 약 2mm 정도로 침투되기 때문에 그 깊이 이후에는
살균효과가 나타나지 않음
cf) 2900 Å 이상 : biotic ray
살균 효과
- 피부 상처나 감염치료에 효과적, 공기 소독
- 3, 4도 홍반 용량 사용
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Other effects of UV radiation 24
UVB - immune system. - Dose dependent
low dose: immune response suppress high dose : activated
UVA – inhibit cyclooxygenase 2 expression and prostaglandin E2 production- psoralen with UVA(PUVA) in the treatment : scleroderma(경피증),
vitiligo(백반증)
PUVA: melamocyte의 성장을 위한 적절한 환경을 조성 UVA: melanocyte의 proliferation과 migration의 직접 자극
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강장효과 2900 Å 이상
2900 Å 이상 : biotic ray
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반자극에 의한 진통효과
3도 홍반 용량 , 국소 치료 시는 크로마이어 등 사용
만성 염증 부위, 외상 후 부작용을 치료할 목적
ex. 퇴행성 관절염, 류마티스 관절염에서 나타나는 심부 조직의 동통 완화
건염 (tendinitis), 섬유증(fibrositis)
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기타 효과
2800 ~3400 Å : 피부암 유발
2900 Å 이상 : 감염에 대한 체내 저항성 증가
대내성 효과(esophylatic effect)
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Psoriasis Wounding healing
Clinical indication for UV radiation
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Psoriasis
Common benign, acute or chronic inflammation skin disease that appears to be based on genetic predisposition
bright red plagues with silvery scales, usually on the knee, elbow, and scalp, mild itching, psoriatic arthritis
Phototherapy
- inactivate cell division and inhibit the DNA synthesis and mitosis of hyperproliferating epidermal cells that are characteristic of psoriasis
Most responsive to PUVA and narrowband UVB alone (311 ~ 313 nm)
Not responsive to UVC and minimal responsive to UVA without drug sensitization
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Psoriatic plaques Robbins and Cotran pathologic basis of disease,
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Psoriasis31
Side effects of PUVA
- epidermal pigmentation
- hyperplasia
- immune suppression
- release of free radical
- carcinogenic (발암성의)
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Wound healing 32
UVC is the frequency band most commonly chosen because it may contribute to wound healing while causing little erythema of tanning
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Contraindications and precautions for the use of UV radiation
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Contraindications for the use of ultraviolet radiation
Irradiation of eyes
- UV opaque goggles for Tx
- UV sensitizing drug (psoralen)를 복용한 환자는 복용 후 12시간 동안 UV
opaque eye protection을 계속해서 착용해야 한다.
Skin cancer
Pulmonary tuberculosis (폐결핵)
Cardiac, kidney, or liver disease
Systemic lupus erythematosus (루프스)
Fever
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Precautions for the use of UV radiation 35
Photosensitizing medications and dietary supplements
Photosensitivity
Recent X-ray therapy
No dose of UV radiation should be repeated until the effects of the previous dose have disappeared
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Burning Premature aging of skin CarcinogenicEye damageAdverse effects of psoralen with UVA
Adverse effects of UV radiation
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37
Figure 13-07. Actinic skin damage (광과민성 피부 질환)
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Application technique 38
The same lamp that will used for treatment should be used to assess a person’s UV sensitivity
Dose response assessment
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Dose response assessment39
Suberythemal dose( SED) :
no change in skin redness occurs in the 24 hours after UV exposure
Minimal erythemal dose (MED)
The smallest dose producing erythema within 8 hours after exposure that disappears within 24 hours after exposure
First degree erythema(E1)
Definite redness with some mild desquamation appears within 6 hours after exposure and last for 1 to 3 days. This dose is generally about 2 ½ times the MED
Second degree erythema(E2)
Intense erythema with edema, peeling, and pigmentation appears within 2 hours or less after treatment and is like a severe sunburn. This dose is generally about 5 times the MED
Third degree erythema(E3)
Erythema with severe blistering, peeling and exudation. This dose is generally about 10 times the MED
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40
Figure 13-08. Set-up for ultraviolet sensitivity assessment
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Determining of MED of UV for an individual 13-1
Application technique 13-1
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Using UVB Using Psoralen with UVA`
UV therapy application
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Dosimetry for the treatment of psoriasis with UV radiation
Repeated exposure로 Tx 진행됨에 따라, tanning, epidermal hyperplasia 등의 결과로서 MED 증가하게 됨
To maintain effective treatment with consistent proportion of MED
- ↑exposure time,
※ 10% ~ 50 % of MED
- ↓distance of the lamp from skin
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Using UVB 44
Dose
- vary from 50% of the MED to E1 dose (about 2 ½ times the MED)
- three to five times weekly
- 15~ 20 treatment to 50% clearance of psoriatic plagues
(total clearance several weeks )
- painful erythema 나타나면 Tx stop
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Using Psoralen with UVA 45
Treatment time : 2 hours after ingestion of drug
Response to PUVA : Delayed onset comparing UVB-induced erythma)
24~48 hours after exposure
2 or 3 times per week
Generally whole body
40%~ 70% of the MED 에서 치료 시작
반응을 유지하기 위하여 매주 10~40% 증가시킨다.
Complete clearance : about 6 weeks
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Documentation 46
If and how psoralen was given
Area of the body treatment
Type of UV radiation used
Serial number of the lamp
Distance of the lamp from the patient
Treatment duration
Response to treatment
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Selecting lamp Lamp maintenance
UV lamp
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자외선 치료 기구
탄소 방전등 (carbon arc lamp) : 자외선 치료에 열적용
수은 증기 방전등 열형 석영 수은등 (hot quarts mercury lamp) : air cool type, 그룹치료(센트로솔) 크로마이어 등 (Kromayer lamp) : water-cool type, 국소용 공냉식 크로마이어등(aero kromayer lamp): air cool type, 국소용 냉형 석영 수은등(cold quarts mercury lamp) : air cool type, 살균용 태양 광선등 (sunlight lamp): 전구형 텅스텐 필라멘트, 가정치료용
형광관그룹치료용 필립관
UV-B 등
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광화학 치료(PUVA)
광화학 치료는 광독성 약물인 psoralen을 바르거나 먹은 후, UVA 를 조사하여 병을치료하는 새로운 치료 방법 UVA (340~400 nm) 중 최대 작용 파장은 340~380 nm
→ 홍반 반응 : 치료 48~72시간에 최고 도달
최소 광독량(MPD, minimal photoxic dose) 이용하여 광량 결정
→ 색소 반응
광독성 반응, 홍반 색소 침착 강하게 일으키며, DNA 합성 억제
건선(psoriasis), 백반증 (vitiligo)
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Selecting lamp
Broad spectrum UVA with 320~400 nm Wide band (250~320 nm) Narrowband (311~312 nm) UVB UVC with 200~290 nm with a peak at 250nm
Arc, Fluorescent type Arc type : small, emit radiation of consistent intensity fluorescent type: long, higher intensity radiation in the middle than ends
Single arc lamp : small area Fluorescent tube : not recommend
∵variability of intensity along the length
narrow band of radiation, uniform treatment of area within a resoneable amount of time
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UV ramp51
A, Fluorescent.
B, Handheld UVA/UVB wand
C, UVB cabinet for whole body therapy
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Laser therapy
정의 : 유도방출에 의한 광증폭장치로써 통증완화와 상처치유에 좋은 효능을 가진다.
일반적인 특성 : 단색광
지향성 : 빛이 퍼지지 않는다.
고휘도 : 단위 입체각에서 나오는 빛의 출력밀도
결합력(응집성) : 광자의 파동위상이 시간적으로 공간적으로 일치함
일반적인 광선의 성질 (반사,산란,전도, 흡수)
레이저치료기의 구성
활성매질 + 여기장치 + 광학강 + 출력장치 + 냉각장치
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의료용 레이저의 종류
CO2 Laser ⇨ 지혈과 동시에 수술이 가능, 파장→10.6 ㎛
He-Cd Laser ⇨ 파장 4416Å
Ar Laser ⇨ 파장 4,885~5254Å
Kr Laser ⇨ 파장 6,471Å, 선택적인 세포 응결
He-Ne Laser ⇨ 파장 6,328Å, 한방의 침술, 온열자극 효과, 물리치료용
YAG ⇨ 파장 1.06 ㎛ 혈우병, 혈소판 감소증, 출혈이 많은 곳의 수술
루비 Laser ⇨ 치과의 충치, 치석제거, 구강종양
N2 Laser ⇨ 생화학 기초 연구
색소 Laser ⇨ 안과영역, 내과의 내시경 사용, 선택적 응결
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Laser 적용방법
치료에너지량(J/㎠)=장비의 출력(W)×치료시간(second)/치료부위의 면적(㎠)
치료방법 조사방법에 따라 : 접촉법과 비접촉법 치료면적에 따라 :
- 격자 조사법 : 작은 부위에 적용하는 방법으로 피하지방조직 치료에 사용- 주사선 조사법 : 막대운동으로 이동하면서 치료
궤양, 화상, 개방성 상처 등에 이용- 점 조사법 : 근막통
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Laser의 치료적 효과
손상조직 치유기간 단축
인체의 직접적인 생체자극으로 원인치료가능
영양효과 증진
진통효과
말초신경재생속도 촉진
외상성 부종이나 혈종감소 효과
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적응증 및 금기증
적응증 :
금기증 임산부 복부조사 눈 주위 치료 악성 종양 바이러스 고환, 난소, 갑상선, 췌장, 부신선 등 월경증 간질 심장조혈기 착용 neoplasm 주위 18세 미만의 골단부위 심부전증, 갑성선 장애, 중증의 정맥성 질환자