SciELO - Scientific Electronic Library Online

 
vol.84 issue3Cutaneous Rosai-Dorfman DiseaseSuperficial granulomatous pyoderma: report of a case of an uncommon variant of pyoderma gangrenosum author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Article

Indicators

Related links

Share


Anais Brasileiros de Dermatologia

On-line version ISSN 1806-4841

An. Bras. Dermatol. vol.84 no.3 Rio de Janeiro July 2009

http://dx.doi.org/10.1590/S0365-05962009000300011 

CASE REPORT

 

Phototherapy (LEDs 660/890nm) in the treatment of leg ulcers in diabetic patients: case study

 

 

Débora Garbin MinatelI; Chukuka Samuel EnwemekaII; Suzelei Castro FrançaIII; Marco Andrey Cipriani FradeIV

IPhysical Therapist, PhD in Biotechnology, Universidade Federal do Amazonas (UFAM) – Manaus (AM), Brazil
IIProf. Dr. School of Health and Life Sciences - New York Institute of Technology – New York, USA
III
Prof. Dr. and Chief Coordinator of the Biotechnology Course, Universidade de Ribeirão Preto (UNAERP) – Ribeirão Preto (SP), Brazil
IV4Prof. Dr. of the Division of Dermatology, Clinical Medicine Department and School Health Center, Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP) – Ribeirão Preto (SP), Brazil

Mailing Address

 

 


ABSTRACT

This study evaluated the use of phototherapy in the healing of mixed leg ulcers in two diabetic patients (type 2) with arterial hypertension. The device had probe 1 (one 660nm LED, 5mW) applied in 3 ulcers and probe 2 (32 890nm LEDs associated with 4 660nm LEDs, 500mW) in 6 ulcers. After asepsis, ulcers were treated with probes to 3 J/cm2, 30sec per point, twice a week, followed by topical daily dressing with 1% silver sulphadiazine during 12 weeks. The following analyses of ulcers with software Image J showed that probe 2 presented mean healing rates of 0.6; 0.7 and 0.9, whereas probe 1 had 0.2;0.4 and 0.6 at 30, 60 and 90 days, espectively. Phototherapy accelerated wound healing of leg ulcers in diabetic patients.

Keywords: Wound healing; Diabetes mellitus; Phototherapy; Laser therapy, Low-level


 

 

INTRODUCTION

Diabetes mellitus is caused by a metabolic disorder in the secretion and/or action of insulin, by hyperglycemia and/or hyperinsulinemia. 1 Type 2 diabetes is characterized by chronic hyperglycemia related to the resistance of target cells to the action of circulating insulin, which leads to degenerative disorders, caused by macro and/or microangiopathy and neuropathy, factors which favor the occurrence of leg ulcers and delay their healing, which in turn justifies the pursuit of new treatment approaches.

In recent years, phototherapy by coherent light (lasers) and incoherent light (LEDs–Light Emitting Diodes) stand out as biostimulant methods for tissue repair2,3, as they increase local circulation, cell proliferation and collagen synthesis.4,5 Several clinical trials have assessed phototherapy for the treatment of many types of chronic ulcers, but they differ as to the types and doses used (wave length, power, intensity), which has led to skepticism as to its real efficacy in tissue healing. Recently, in studies conducted in our facility, Caetano et al.6 (2008) demonstrated that phototherapy accelerates the healing of chronic venous ulcers as compared to a topical dressing with 1% silver sulphadiazine or placebo light therapy.

In this manner, we are trying to demonstrate the use of phototherapy (660/890nm LEDs) associated to topical silver sulphadiazine in the healing of leg ulcers in two diabetic patients.

Clinical cases
After signing a Free and Informed Consent Form (HCFMRP/USP Process # 302/06), two randomly selected diabetic patients (type 2) were treated at the Ulcer Outpatient Clinic of the Dermatology Department of the School Health Center-FMRP-USP.

The phototherapy equipment (Dynatron Solaris¿) used had a 1-P1 probe (1 660nm LED, 5mW) and 2-P2 probe (32 890nm LEDs and 4 660nm LEDs, 500mW).

After cleaning the ulcers with 0.9% saline solution, the probes were directly applied specifically on the wounds protected with PVC, at the dose of 3J/cm2, 30seg/5cm2, 2x/week, followed by daily dressings of 1% silver sulphadiazine (SDZ) cream for twelve weeks of treatment.

 

CASE REPORTS

Case 1: Brown 77-year-old woman with type 2 diabetes, hypertension and chronic venous insufficiency (CVI), user of Metformin (1700mg/d) and Captopril (50mg/d). She had systemic hypertension (SH), was on a wheelchair, and had had mixed leg ulcers for 25 years, having undergone several topical treatments. Clinical-dermatological examination showed that both legs had painful ulcers, edema, brownish dermatitis, lipodermatosclerosis and varicose veins. She had 2 ulcers (Figures 1.1 and 1.2) on the left lower limb (LLL) that were treated with P1; and 4 ulcers on the RLL treated with P2 (Figures 1.3, 1.4, 1.5 and 1.6).

Case 2: Brown 50-year-old man with type 2 diabetes, who had been on insulin therapy (22/10 UI day) for one year, hypertensive for 20 years, with stroke sequelae, on a wheelchair, with multiple painful leg ulcers on both legs, associated to signs of CVI. Upon examination, he had an ulcer on the RLL for one month (Figure 2.1) treated with P1, and 3 ulcers on the LLL with a course of 10 months (Figure 2.2, 2.3, 2.4) treated with P2.

 

 

 

 

Capture of ulcer images for analysis

Ulcers were assessed weekly with a digital camera (Sony¿ DSC-P100), mounted on an aluminum base with a millimeter rule at 30cm and perpendicular to the ulcer. Image J¿ software estimated the total area of the ulcers with the delimitation of edges and calculated the ulcer healing rate [UHR=(Initial Area–Final Area)/Initial Area)]7, where UHR=1 represents total reepithelization; UHR=0 no signs of reepithelization; UHR>0 reduction and UHR< 0 increase of the ulcer area.

The tissue present on ulcers had its color definition evaluated by the plugin threshold color of Image J¿ software, where the color red corresponded to granulation tissue (G) and yellow, to necrosis/fibrin (N) (devitalized tissue).8 The speed of tissue modifications during treatment was established by the necrosis/granulation ratio (N/G) at the moment of evaluation, where N/G=1 shows that the area of granulation is equal to necrosis; N/G<1 shows that the area of granulation larger than necrosis, in contrast with N/G>1, when granulation is smaller than necrosis.

Analysis of results

Tables 1 and 2 describe the clinical-therapeutic evolution of initial areas and their respective UHRs and N/Gs on the 30th, 60th and 90th days of treatment with P1 and 2, respectively. Figures 1 and 2 show the initial (a) and final (b) clinical-photographic evolution associated to their respective two-weekly UHR evolutions.

The evolutional analysis of the ulcers with Image J¿ software demonstrated that 6 ulcers treated with P2 presented average UHRs of 0.6; 0.7 and 0.9 (Table 2), while 3 ulcers treated with P1 have average values of 0.2; 0.4 and 0.6 on the 30th, 60th and 90th days (Table 1), respectively.

Ulcers 1.4 and 1.6 treated with P2 presented total reepithelization in 7 and 12 weeks of treatment, respectively (Table 2 and Figure 1). On the other hand, ulcers treated with P1 (Figure 1.2 and 2.1), which presented pain during treatment, showed slight signs of healing after the 5th week of treatment (Figures 1 and 2, Table 1). Ulcer 1.2 had a UHR of 0.4 and N/G of 0.7 on the 90th day due to its location above the calcaneous tendon.

However, in both cases the ulcers treated with P2 progressed with satisfactory healing, followed by a report of less pain on the ulcers right on the 2nd week of treatment (Table 2).

 

DISCUSSION

Diabetes mellitus is a multifactor and chronic syndrome that evolves with many complications triggered by macro and microangiopathy and/or by neuropathy, affecting multiple organs such as kidneys, retina, heart, and skin. These complications associated to comorbidities like CVI and hypertension, increase the likelihood of leg ulcers.9 Moreover, diabetic patients are susceptible to traumas, infections and, consequently, ulcers, which are to be noted for their usually slow treatment with poor results, which reduces the quality of life of these patients, and may evolve to amputation and death.10,11.

The healing of ulcers is a complex biological sequence that includes cellular and molecular processes, such as inflammation, tissue formation (angiogenesis, fibrogenesis and reepithelization) and tissue remodeling. Clinically, the characteristics of the tissue of the ulcers reflect the phase of the healing process they are in, like necrotic or yellowish tissue (necrosis) in the initial inflammatory phase. Next, reddish and granulated tissue forms (angiogenesis), which then becomes a darker/crimson compact tissue without the granulated aspect (fibroplasia). Finally, the surface of the ulcer diminishes, especially due to the reepithelization of the edges and/or reepithelization islets. Therefore, this tissue shows the dynamic features of ulcer healing, which may be documented in percentages, representing improvement or deterioration of healing along time.8

Clinical trials show different ways to assess and quantify the evolution of healing provided by new treatments for chronic ulcers,7,12 like the variation of the percent reduction of the ulcer area (Ai-Af/Ai)x100, which enables demonstrating their efficacy and comparing different treatments, normalizing different ulcer sizes, and can be used in short-term clinical tests with a small sample, in addition to indicating quantitatively their continuity or modification during the course.

Image J® software permitted having a clinical-photographic assessment of the ulcers and quantifying their surface areas and tissue changes during treatment, which enabled demonstrating and quantifying the dynamic evolution of the healing of skin ulcers.13

The ulcers treated with P2 in both cases showed greater reduction of the total area than the ulcers treated with P1. Location was a noteworthy aspect in the case of the calcaneus tendon (ulcer 1.2), which evolved with a smaller UHR, reaching 0.4 UHR in 90 days (Table 1 and Figure 1), probably related to the poorer vascularization of the site due to CVI, lipodermatoesclerosis and physical inactivity of the patient. This fact is confirmed by the evolution of the N/G ratio on the 30th day, 2.4, thus indicating that the inflammation increased, stabilized on the 60th and 90th days, then followed by a reduction of the ulcer area.

The results obtained corroborate the evidence that phototherapy through LEDs at 600-1000nm promotes tissue repair, particularly in the cases of chronic ulcers2,3. The positive effect of P2 to treat chronic ulcers in diabetic patients should be noted, as observed by Kleinman et al., who found that 50% to 90% of the diabetics ulcers responded positively to laser therapy with 785nm, as well as to its combination with 632.8nm.14 Sugrue et al. also reported positive results of laser for many types of wounds and ulcers, especially in chronic and refractory cases.15 No adverse effect was informed in any of these studies. In partnership with the New York Institute of Technology (USA), similar results were observed in our facility with (660/890nm) phototherapy in the healing of chronic venous ulcers when compared to placebo light therapy and daily topical SDZ6.

Results suggest that the association of LEDs (660/890nm) twice a week with daily topical SDZ showed greater efficacy in healing when compared to P1 (1 LED). It is a biostimulant noninvasive easy-to-use and fast-application therapy with an additional analgesic effect for the treatment of leg ulcers in diabetic patients; however, more randomized clinical trials are required to consolidate our findings.

 

REFERENCES

1. DeFronzo RA, Ferrannini E. Insulin resistance. A multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care. 1991;14:173-94         [ Links ]

2. Smith KC. Laser (and LED) therapy is phototherapy. Photomed Laser Surg. 2005;23:78-80         [ Links ]

3. Vladimirov YA, Osipov AN, Klebanov GI. Photobiological principles of therapeutic applications of laser radiation. Biochemistry. 2004;69:81-9         [ Links ]

4. Minatel DG, Frade MAC, França SC, Enwemeka CS. Phtototherapy promotes healing of chronic diabetic leg ulcers that failed to respond to other therapies. Lasers in Surgery and Medicine. 2009; DOI: 10.1002/ lsm. 20789         [ Links ]

5. Desmet KD, Paz DA, Corry JJ, Eells JT, Wong-Riley MT, Henry MM, et al. Clinical and experimental applications of NIR-LED photobiomodulation. Photomed Laser Surg. 2006;24:121-8         [ Links ]

6. Caetano KS, Frade MAC, Minatel DG, Santana LA, Enwemeka CS. Phototherapy improves healing of chronic venous ulcers. Photomed Laser Surg. 2009;27:111-8         [ Links ]

7. Robson MC, Hill D, Woodske ME, Steed DL. Wound healing trajectories as predictors of effectiveness of therapeutic agents. Arch Surg. 2000;135:773-7         [ Links ]

8. Fowler EM, Vesely N, Johnson V, Harwood J, Tran J, Amberry T. Wound care for persons with diabetes. Home Health Nurse. 2003;21:531-40         [ Links ]

9. Frade MAC, Cursi IB, Andrade FF, Soares SC, Ribeiro WS, Santos SV, et al. Úlcera de perna: um estudo de casos em Juiz de Fora-MG (Brasil) e região. An Bras Dermatol. 2005;80:41-6         [ Links ]

10. Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000;23:606-11         [ Links ]

11. Frade MAC, Cursi IB, Andrade FF, Coutinho-Netto J, Barbetta FM, Foss NT. Management of diabetic skin wounds with a natural latex biomembrane. Med Cutan Iber Am. 2004;32:157-62         [ Links ]

12. Margolis DJ, Gelfand JM, Hoffstad O, Berlin JA. Surrogate end points for the treatment of diabetic neuropathic foot ulcers. Diabetes Care. 2003; 26: 1696-700         [ Links ]

13. Gomes FG, Santana LA, Minatel DG, Frade MAC. Uso do software Imaje J® para análise clínico-fotográfica das úlceras. In: 5o Encontro de Bioengenharia São Carlos. Caderno de Resumos do 5º EncoBio. São Carlos: USP; 2005. p. 37         [ Links ]

14. Kleinman Y, Simmer S, Braksma Y, Morag B, Lichtenstein D. Low level laser therapy in patients with venous ulcers: Early and long term outcomes. Laser Ther. 1996;8:205-8         [ Links ]

15. Sugrue ME, Carolan J, Leen EJ. The use of infra-red laser therapy in the treatment of venous ulcerations. Ann Vasc Surg. 1990;4:179-81        [ Links ]

 

 

Mailing Address:
Prof. Dr. Marco Andrey Cipriani Frade
Divisão de Dermatologia da Faculdade de
Medicina de Ribeirão Preto - USP
Av. Bandeirantes 3900.
14048 900 - Ribeirão Preto - SP
Tel./fax: 55 16 36330236
e-mail: mandrey@fmrp.usp.br

 

 

Conflict of interest: None
Financial funding: CNPq e Fundação de Apoio ao Ensino, Pesquisa e Assistência do Hospital das Clínicas da Faculdade Medicina de
Ribeirão Preto (FMRP-USP).
How to cite this article: Minatel DG, Enwemeka CS, FrançaSC, Frade MAC. Fototerapia (LEDs 660/890nm) no tratamento de úlceras de perna em pacientes diabéticos: estudo de caso. An Bras Dermatol. 2009;84(3):279-83.