Page Four P H Y S I O T H E R A P Y October, 1953. Some of the Uses of Ultra-Violet Rays in Dermatology By R. M. B. MacKENNA, M.A., M .D ., M .B., B.Ch., F.R.C.P. Physician in Charge, Dermatological Dept., S t. Bartholomew's Hospital, London and T. WAREHAM, M .C .S.P. Superintendent o f the Physiotherapy Dept., S t. Bartholomew's Hospital, London. (With acknowledgement to The British Journal Physical Medicine). IN THIS paper we propose discussing the •treatment o f four skin diseases (psoriasis, cutaneous tuberculosis, acne vulgaris and alopecia areata) with ultra-violet rays, these being the four principal maladies within our purview for which this type o f treatment is o f benefit. Psoriasis There is little doubt that the average psoriatic skin requires a relatively large am ount o f sun, or ultra-violet ray, for its full health, and many persons prone to this malady keep this disease at bay, if not com pletely in abeyance, by careful and regular irradiation at hom e. I f the individuals use com m on sense there seems to be little danger in this custom. The danger o f provoking cutaneous pre- cancerosis and epitheliom as is greater in theory than in practice. When the malady has developed, the Goecker- man Regim e, or a m odification o f this, is by far the m ost satisfactory m ethod o f treatment. Adm ittedly the R egim e is an in-patient one, but can be modified for out-patient treatment, and also for use in the home. The m odification we use for in-patients is as fo llo w s:— W hite’s Tar Paste (N ational Formulary, 1952), adjusted to contain a variable am ount o f coal tar in accordance w ith the type o f individual con- concerned, is em ployed (briefly, other things being equal, the m ore brunette the patient, the stronger the concentration o f tar which can be em ployed), 4 per cent, is a satisfactory concentration for m ost skins. The paste is well rubbed into the lesions by hand. N ext morning the patient has a tar bath made by adding 2 -4 ozs. o f liquor picis carbonis or Liquor Carbonis Detergens to 25 gallons o f h o t water. When in the bath, loose scales are gently removed. Then liquid paraffin is applied to all the areas which are to be exposed to ultra-violet rays. This application o f liquid paraffin is an im portant part o f the treatment. A ny paste remaining on the skin should be removed with it; the paraffin keeps the horny layer o f the epidermis supple, and contrary to the general opinion, unlike vegetable oils, is a highly efficient transmitter o f ultra-violet rays. The details o f ultra-violet irradiation are as follow s. The day before starting treatment, a test dose is done, so that an exact estimate is made with each patient o f the dose required to produce a first degree erythema (E .I.), that is a dose which produces a mild erythema that quickly fades and is not follow ed by any visible desquamation. W hen receiving treatment the patient is com ­ pletely stripped. The H anovia “A lpine Sun” Lamp is used at a distance o f 18 inches. The first day, the anterior and posterior aspects o f the trunk and legs are irradiated in four areas; the lamp is centred at the xiphoid when treating the trunk, and at the knee when treating the legs.. The legs should n t be covered when irradiating th e ' trunk, or vice versa. The second day, the sides o f the trunk and legs are treated, again in four areas; the third day the same areas as on the first day, and so on. The progression o f the dose is m ost important; a mild E .l. is kept up by increasing the time by 20 per cent, o f the previous dose. Stronger doses cause peeling which delays further treatment. Sub-erythema doses have not been found to be nearly as beneficial. Before starting treatment at each attendance, the physiotherapist finds out what reaction was obtained with the previous dose; she enters this in the records and then estimates the next dose in the light o f this knowledge. It is obvious that m eticulous records must be kept by the physiotherapist. After each irradiation the tar paste is applied to all the lesions and the patient returns to bed. Every m orning the routine o f tar bath, liquid paraffin application, ultra-violet irradiation and application o f tar paste, is repeated. A utohaem o- therapy using 5 -1 0 millilitres o f blood is also given once every five days, and som e patients benefit if they receive small doses o f a sedative. By the proper use o f this m ethod an extensive eruption can be removed in an average period o f about 17 days; by this time there is usually som e pigm entation o f the skin with areas o f leucoderma to mark the sites where the lesions have been present. N o te that this regime is dangerous for those having latent or active tuberculosis, because this infection may be accentuated by the irradiation. Therefore full investigation must be made in each case before the regime is commenced. The principle o f tar treatment lies in the fact that tar is a photo-sensitizing agent, and that the beneficial effect o f the rays is considerably enhanced by the tar paste and the tar baths; possibly there is m ore from the biochem ical standpoint which can be added, but in the present state o f our knowledge it is inadvisable to make further com m ent. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) October, 1953. P H Y S I O T H E R A P Y Page Five It will be obvious to the reader that the treatment can be carried out at hom e i f the patient does not object to the staining o f his sheets by the tar paste. It m ay be modified for out-patient treatment, but the time required to achieve removal o f the lesions is usually longer. A similar procedure is adopted in out-patient treatment. A t each attendance the patient has a tar bath, is then rubbed all over with the liquid paraffin and then is irradiated over four areas. A s the irradiation time increases, the total treat­ ment becomes too long, so, in the latter stages only, two areas are treated at each attendance, an accurate E .l. still being obtained by progressing as before. A course may last 6 -1 0 eweks, then a rest is given follow ed by a further course if neces­ sary. With som e patients, a stubborn patch m ay |remain when the rest o f the skin has cleared; this may be given local ultra-violet ray treatment with considerably stronger doses. It is interesting that severe concom itant psoriasis o f the scalp clears more quickly i f treated by giving strong high-frequency sparks to the w hole scalp for twenty minutes at each attendance. Cutaneous tuberculosis The treatment o f lupus vulgaris and other forms o f cutaneous tuberculosis by ultra-violet ray has been so much discussed since the days o f Finsen, that w e will not make more than a few com m ents about this matter. Perhaps because o f im prove­ ment in purity o f milk supplies as well as because o f better general standards o f hygiene and nutrition, our reticence is som ewhat stimulated by the fact that this group o f diseases, once all too com m on in this country, is now rare. Further, there is some tendency for the treatment o f lupus by ultra­ violet ray to be concentrated in a few centres where the Finsen-Lom holt lamp is available; the proper I use o f this apparatus can be learned only at such a centre, and technical descriptions are available in several standard books. Therefore we will co n ­ fine our com m ents to the use o f the water-cooled Kromayer lamp, but before doing this it is perhaps worth noting that the m ost modern treatments o f cutaneous tuberculosis (for example calciferol, streptomycin with ^ara-am inosalicylic acid, and derivatives o f /so-nicotinic acid), often, particularly with the first named, succeed in clearing wide areas o f the infection but leave islets o f lupus tissue am ong the scar tissue. These m ay be dealt with by chemical cauterization, but in selected cases the Kromayer lamp may be used for this purpose. If, in the treatment o f the infection, it is decided that the Kromayer lamp shall be used the technique we prefer is as follow s. Very strong blister doses are given with contact and firm pressure. A bout five times the minimum dose that w ould be required to produce a blister is given. Each active area and a margin beyond is treated in rotation and, when all peeling has ceased, a further blister dose is given and repeated to each area four times. A general carbon-arc treatment m ay also be given at the sam e time. I f reliance is placed on ultra-violet ray treatment alone, patience and perseverance are required on the part o f the patient as treatment m ay extend over many months. Acne vulgaris D esp ite the conflicting theories concerning the aetiology o f acne vulgaris, it has formerly been recognized that heliotherapy (particularly when associated with sea-bathing) is often reasonably successful in curing or causing am elioration in acne vulgaris in otherwise healthy subjects. U ltra­ violet rays derived from a mercury vapour lamp are often m ore successful for local treatment but therapy with the carbon-arc lamp with its wider spectrum is frequently more beneficial for general treatment. Probably in the early, com edo, stage, routine derm atological treatment is all that is required ; it is in the pustular stage that the rays are m ost beneficial when properly employed. It m ay be helpful to note that mild derm ato­ logical treatment o f the skin need not be discon­ tinued during the period that ultra-violet ray is given, provided the follow ing two item s are rem em bered:— (1) The skin must be carefully cleansed o f medica­ ment before treatment is em ployed. (2) The derm atological treatment m ust not consist o f strongly exfoliative applications, for i f these are used the skin will becom e sore and ultra­ violet ray treatment w ill have to be delayed or modified. Calamine lotion with 2 per cent, precipi­ tated sulphur or a weak sulphur cream are the two remedies which w e have found to be o f m ost benefit in these circumstances. The physiothera­ peutic technique is, briefly, as follow s. Before starting treatment, a test dose is done on a similar area o f skin elsewhere on the body. A m ild peeling dose is given to these patients (E.2.) and it is important that further irradiation is not given to any area until all peeling has stopped. Therefore each area can only be irradiated about once in each time by increasing the time by about 40 per cent. A t the intervening attendances general carbon-arc treatment m ay be given to other parts o f the body using suberythema doses. Som e cases benefit by local shortwave diathermy to the peeling areas to increase the local circulation. The tech­ nique o f irradiation is specialized, as a good cosm etic effect is o f first im portance. Harsh lines o f demarcation from protecting towels must, as far as possible, be avoided. For exam ple, when treating the face, the skin is well washed with soap and water and any large R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Six P H Y S I O T H E R A P Y October, 1953. blackheads gently removed. The eyelids are coated with paraffin on to which is placed a wisp o f cotton w ool; the tips o f the ears are lightly smeared with grease and the tip o f the nose is dusted with powder (otherwise it tends to receive m ore rays than the surrounding skin). I f the neck is clear o f spots, a towel m ay be wrapped round it and the rest o f the body covered. The face is then irradiated w ithout other protection from three aspects; one parallel w ith the forehead, and two parallel with the zygom atic arches the lam p being centred on a level with the nose. Similarly, when the back and shoulders are to be treated, only the head and the lower lim it o f irradiation are covered. The patient sits on a stool and is irradiated in four aspects; two with the lamp parallel with the scapulae at the level o f the inferior angles, and two with the lam p above, parallel with the oblique upper fibres o f trapezius; usually, the first two areas are treated at one atten­ dance and the second two at the next. This m ethod obviates any unsightly lines where the reaction ceases suddenly at a tow el protection line. Alopecia Here we are concerned only with alopecia areata. The cause o f this type o f baldness is unknown, and the action o f ultra-violet rays and the other measures discussed here appears to be solely to stimulate the m etabolic activities o f the scalp. W e have found that, for many cases, a com bina­ tion o f ultra-violet rays and high frequency sparks is beneficial (though critics w ould perhaps accuse us o f falling into the logical fallacy o f arguing p o s t hoc ergo p ro p ter hoc). , T he technique used is as follow s. T he skin is first cleansed o f grease with m ethylated ether and then fairly strong peeling doses are given to each patch. A s before, further irradiation cannot be given until all peeling has stopped. The patient must continue to attend and is treated by strong high-frequency sparks for twenty m inutes at each attendance until the patch is ready for further irradiation. When the course is com plete the ultra-violet ray is stopped but the high-frequency is continued twice a week until, after a suitable interval, another course o f ultra-violet ray is given. It is our custom to allow these patients to co n ­ tinue on treatment for many m onths, as often three or four courses are necessary. A s the patients administer the high-frequency to themselves (under supervision) they take up very little o f the physio­ therapists’ time. Envoy U ltra-violet rays may, in our opinion, be success­ fully used in four cutaneous maladies, as described above. Because the rays stim ulate the m etabolic activities o f the skin, it m ay be presumed that they will also increase the powers o f self-disinfec­ tion o f the skin. Cases o f persistent furunculosis (not associated with systemic disease) m ay be successfully treated, particularly with carbon-arc therapy; but we would make no further claims than those in a general outline o f the usefulness o f ultra-violet ray in dermatology although others, doubtless, ■ would add certain other m aladies (for example indolent cutaneous ulceration, indolent wounds and pressure sores) to our brief list. G EN ER A L We welcome the following new members to th e Society: M rs. Elliott an d Miss L. Bradley, both o f Port Elizabeth. Miss M uriel Miller, Miss M ary G am m on, Missl R iva C ohen and Miss Bobrow, all o f Johannesburg. * * * The final year physiotherapy students a t W itw atersrand University held their annual dance a t th e Langham Hotel on Septem ber 1st, it was a m ost enjoyable evening. $ * * Miss A. M . Smith, the part-tim e paid Secretary em­ ployed t y the Society has found it necessary to resign her position. This will be a great loss to the .Society, and may we th a n k her for all th at she has done for us in the past year. * * * Telegrams o f good wishes were sent to the W orld C onfederation o f Physical Therapy, on the occasion o f the F irst International Congress. # » * Miss M arjorie H um phrey is acting as Senior Physio­ therapist at the Johannesburg G eneral H ospital in the absence o f Miss Lois Dyer. PERSONAL Miss H azel P arfram ar, M .C .S.P., was married on July 25th, to M r. Geoffrey Barnes. Miss M ary N ichol, B .Sc.(Rand.), was m arried to ( M r. Evan Williams in E ast L ondon on July 13th. Miss Betty Andrews, B .Sc.(Rand.), was m arried to D r. D errick D ell in Johannesburg, on Septem ber 2nd. M ay we wish them all every happiness for the future. Miss L ola Todes has announced h er engagem ent to M r. Cecil B ersor o f Cape Town. Miss M uriel M iller has also announced her engage­ ment to M r. Joe G oodm an. EASTER STAM P CAMPAIGN, 1953. T he efforts o f all those who helped w ith the E aster Stam p C am paign were greatly appreciated by the South A frican C are o f Cripples A ssociation. Stam ps sold by individual Physiotherapists am ounted to £52. 5s. Od. while th e tables a t A nsteys and T attersalls sold £99. 12s. 6d. and £24. 3s. 5d. respectively. These are ever greater am ounts th an last year. T hank you all for your help. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )